Student Workbook Calculating Dosages Online

Transcription

1 Student Workbook Calculating Dosages Online Sandra Luz Martinez de Castillo, RN, MA, EdD Nursing Professor Los Medanos College Pittsburg, California and Maryanne Werner-McCullough, RN, MS, MNP Nursing Professor Contra Costa College San Pablo, California F. A. Davis Company Philadelphia

2 F. A. Davis Company 1915 Arch Street Philadelphia, PA Copyright 2012 by F. A. Davis Company Copyright 2012 by F. A. Davis Company. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Printed in the United States of America Last digit indicates print number: Senior Acquisitions Editor: Thomas Ciavarella Director of Content Development: Darlene Pedersen Senior Project Editor: Meghan Ziegler Illustration and Design Manager: Carolyn O Brien As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs. Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.25 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is: / $.25. Copyright 2012, F. A. Davis Company

3 Contents Module Page Basic Math Review 1 Methods of Calculation 8 Systems of Measurement 14 Intake and Output 21 Reading Medication Labels 31 Oral Medications 41 Syringes and Needles 51 Parenteral Medications 61 Reconstitution of Powdered Medications 72 IV Calculations 85 Pediatric Calculations 103 Titration of IV Medications 115 Answers 121 Copyright 2012, F. A. Davis Company

4

5 Module: BASIC MATH REVIEW FRACTIONS KEY POINTS: Check the denominators before adding and subtracting fractions. If they are different, find the lowest common denominator, then solve the problem. For multiplication of fractions, just multiply the numerators and the denominators. For division of fractions, remember to invert the second fraction. Then, multiply the numerators and the denominators. Change all mixed numbers to improper fractions before working out the problem. Simplify all fractions to the equivalent fraction. Working With Addition of Fractions Add the following fractions and mixed numbers. 1. 2/5 + 1/5 = 2. 2/ /42 = 3. 2/5 + 2/3 = /8 + 3/4 = /4 + 1/ /2 = / / /4 = / / /3 = 1 Copyright 2012, F. A. Davis Company

6 8. 6 7/ / /6 = / / /8 = / / /8 = Working With Subtraction of Fractions Subtract the following fractions and mixed numbers. 1. 5/6 1/3 = 2. 8/10 1/2 = 3. 7/8 2/3 = /4 1 3/8 = /2 3 1/5 = /6 5 2/3 = /5 6 7/8 = /8 9 2/3 = /7 4 5/6 = /2 3 2/5 = 2 Copyright 2012, F. A. Davis Company

7 Working With Multiplication of Fractions Multiply the following fractions and mixed numbers. 1. 6/8 2/5 = 2. 10/9 1/2 = 3. 5/12 1 1/5 = /8 3/10 = /2 3 3/5 = /3 4 3/7 = /6 1 1/8 = /7 2 2/5 = /8 3 2/3 = /9 2 11/12 = Working With Division of Fractions Divide the following fractions and mixed numbers. 1. 7/10 1/2 = 2. 1/150 1/3 = 3. 6/8 3/5 = /7 1/2 = /2 3 3/4 = 3 Copyright 2012, F. A. Davis Company

8 6. 2 2/5 5 4/5 = /8 7 1/2 = /9 3 1/3 = /7 1/7 = /2 8 3/4 = DECIMALS KEY POINTS: When adding and subtracting decimals, make sure that the decimal points are lined up directly under each other. For multiplication of decimals, count the total number of decimal places in the numbers to be multiplied. Then, count the same number of decimal places in the answer and place the decimal point. When dividing decimals, if there is a decimal point in the divisor, move the decimal point to make the divisor a whole number. Then, move the decimal point in the dividend the same number of decimal places. Place the decimal point in the answer in the same place as in the dividend. Working With Addition of Decimals Add the following decimals = = = = 4 Copyright 2012, F. A. Davis Company

9 = = = = = = = = Working With Subtraction of Decimals Subtract the following decimals = = = = = = = = = = = = 5 Copyright 2012, F. A. Davis Company

10 Working With Multiplication of Decimals Multiply the following decimals = = = = = = = = = = = = Working With Division of Decimals Divide the following decimals = = = = = = 6 Copyright 2012, F. A. Davis Company

11 = = = = = = 7 Copyright 2012, F. A. Davis Company

12 Module: METHODS OF CALCULATION SELECT A METHOD OF CALCULATION Linear Ratio and Proportion: 5 mg : 1 tab :: 10 mg : x tab Fractional Ratio and Proportion: 5 mg = 10 mg 1 tab x tab Dimensional Analysis: 10 mg 1 tab = x tab 1 5 mg Formula: 10 mg 1 tab = x tab 5 mg KEY POINTS: Learn the method of your choice; study the setup. To arrive at the correct answer, the units of measurement must be set up so that they cancel. Working With a Method of Calculation Solve the following problems using the method of your choice. 1. The order is for 50 mg. The pharmacy sends 25 mg tablets. How many tablets will the nurse give? 2. The order is for 75 mg. The pharmacy sends 50 mg scored tablets. How many tablets will the nurse give? 8 Copyright 2012, F. A. Davis Company

13 3. The order is for 1 mcg. The pharmacy sends 0.5 mcg pills. How many pills will the nurse give? 4. The order is for 0.5 g. The pharmacy sends 1 g scored tablets. How many tablets will the nurse give? 5. The order is for 1.2 gram. The pharmacy sends 0.4 gram caplets. How many caplets will the nurse give? 6. The order is for 7 mg. The pharmacy sends an elixir labeled 2 mg / ml. How many ml will the nurse give? 7. The order is for 90 mg of a drug. The pharmacy sends 30 mg / 2 ml. How many ml will the nurse give? 8. The doctor orders Lanoxin 125 mcg daily. The nurse finds the following in the patient s medication drawer. How many ml of Lanoxin will the nurse administer? Lanoxin 500 mcg per 2 ml 9 Copyright 2012, F. A. Davis Company

14 9. The order is for IV ranitidine 75 mg q.8h. The pharmacy sends the following vial of ranitidine. How many ml will the nurse give per dose? Ranitidine for Injection 25 mg / ml 10. The order is for 100 mg. The pharmacy sends an oral suspension labeled 12.5 mg / 2 ml. How many ml will the nurse give? 11. The order is for amoxicillin/clavulanate 250 mg t.i.d. The pharmacy sends the following medication. How many days will the bottle last? Amoxicillin/Clavulanate Potassium Tablets 250 mg / tablet Contains 30 tablets 10 Copyright 2012, F. A. Davis Company

15 12. The order is for 125 mg b.i.d. The pharmacy sends a 200 ml bottle labeled 12.5 mg / ml. How many days will the bottle last? 13. The order is for gram of medication IM stat. The pharmacy sends a vial of the medication labeled 0.01 gram per 1.5 ml. How many ml will the nurse administer? 14. The physician orders 21 mg p.o. t.i.d. The nurse has a 100 ml bottle labeled 6 mg / ml. How many ml will the patient receive per dose? 15. The patient is to receive 60 mcg p.o. q.am. The nurse has a bottle labeled 4 mcg / 2 ml. How many ml will the patient receive each day? 16. The physician orders heparin sodium 6000 units subcut q.12h. The pharmacy sends the following vial of heparin. How many ml will the patient receive per dose? Heparin Sodium 10,000 units / ml 11 Copyright 2012, F. A. Davis Company

16 17. The doctor orders 0.4 mg of a drug b.i.d. The pharmacy sends a bottle labeled 0.4 mg per pill. The bottle contains 30 pills. How many days will this bottle last? 18. The patient has an order for amoxicillin oral suspension 500 mg q.8h. The medication drawer contains the following bottle of amoxicillin. How many ml will the patient receive per dose? Amoxicillin Oral Suspension 125 mg in 5 ml For oral use only. Shake well before use. 19a. The doctor orders 0.4 mg of a medication b.i.d. The pharmacy sends a vial labeled 1 mg / ml. How many ml will the patient receive? b. If the vial contains 2 ml, how many doses are available in the vial? 12 Copyright 2012, F. A. Davis Company

17 20a. The order is for heparin 8000 units subcut now. The pharmacy sends the following dose of heparin. Calculate the number of ml the patient will receive. Heparin Sodium 10,000 units / ml Multidose vial containing 4 ml b. How many doses will the nurse be able to give from the above vial? c. If the order is changed to heparin 6500 units subcut daily, how many ml will the patient receive per dose? d. How many doses of 6500 units subcut daily will the nurse be able to give from the multidose vial? 13 Copyright 2012, F. A. Davis Company

18 Module: SYSTEMS OF MEASUREMENT METRIC SYSTEM: UNITS OF MEASUREMENT Kilo Hecto Deka BASIC Deci Centi Milli Micro UNIT KEY POINTS: Memorize the metric units of measurement, metric abbreviations, and the metric line. Working With the Metric System Fill in the blanks with the correct answer L = _ ml L = _ ml mg = _ gram mcg = _ mg mg = _ mcg 6. 2 mg = _ mcg mg = _ gram ml = _ L cm = _ dm km = _ m cm = _ mm kg = _ g 14 Copyright 2012, F. A. Davis Company

19 ml = _ L g = _ mg 15. The patient receives vancomycin 750 mg IV b.i.d. How many g does the patient receive per dose? _ 16. The patient has an order for 0.5 g of ampicillin. How many mg will the nurse administer? _ 17. The patient receives levothyroxine 75 mcg p.o. q.am. How many mg does the patient receive? _ 18. The doctor s order is for digoxin elixir 0.45 mg p.o. now. This dose is equivalent to mcg. _ 19. The weight of a medication is 1.2 kg. This is equivalent to g. _ 20. A wound measures 4 cm in length. This is equivalent to mm. _ 21. The patient has an order for Versed 7 mg IV. The pharmacy sends a vial of Versed labeled 5 mg / ml. How many ml will the nurse administer? _ 15 Copyright 2012, F. A. Davis Company

20 22. The drug order is for lactulose 1000 mg p.o. b.i.d. for the patient. The pharmacy sends a container labeled lactulose 1 g / 10 ml. How many ml will the nurse administer per dose? _ 23. The doctor orders Solu-Medrol 125 mg IV q.12h. for the patient. The pharmacy sends Solu-Medrol 0.25 g / ml. How many ml will the nurse administer per dose? _ 24. The physician writes an order for Benadryl 50 mg orally q.6h. as needed for the patient. The nurse has a bottle of Benadryl labeled 12.5 mg / 5 ml. How many ml will the nurse administer per dose? _ 25. The nurse is preparing to administer 750 mg of vitamin C to the patient at 9:00 AM. In the patient s medication drawer, the nurse finds vitamin C tablets labeled 0.5 g / tablet. How many tablets will the nurse administer to the patient at 9:00 AM? _ 26. The order is for lorazepam 0.5 mg IM now. The nurse has a vial of lorazepam labeled 2 mg / ml. How many ml will the nurse administer to the patient? _ 16 Copyright 2012, F. A. Davis Company

21 HOUSEHOLD SYSTEM: UNITS OF MEASUREMENT UNIT EQUIVALENT ABBREVIATION MEASUREMENT 1 glass 8 ounces -- 1 cup 8 ounces -- 1 teacup 6 ounces -- 1 tablespoon 3 teaspoons T, Tbs 1 teaspoon 5 ml t, tsp 1 drop (drops) -- gt (gtt) 2.2 pounds 1 kilogram lb KEY POINTS: Memorize the units of measurement, equivalent measurements, and symbols used in the household system. Working With the Household System Fill in the blanks with the correct answer. 1. Two Tbs = tsp 2. One ounce = T 3. One-half ounce = tsp 4. Two glasses of juice = oz 5. One cup = oz 6. 2 kg = lb 17 Copyright 2012, F. A. Davis Company

22 7. Three tsp of an antacid = T Fill in the medicine cup below. 2 TBS 1 TBS 1 TSP 1/2 TSP 8. The nurse administers 2 tsp of cough syrup to the patient. How many ml will the nurse administer? Fill in the medicine cup below. _ 30 ml 25 ml 20 ml 15 ml 10 ml 5 ml 9. The patient drinks 3 glasses of water. How many ounces did the patient drink? _ 10. The nurse gives the patient a cup of broth. How many ounces is this? _ 18 Copyright 2012, F. A. Davis Company

23 CONVERSIONS BETWEEN SYSTEMS: UNITS OF MEASUREMENT UNIT EQUIVALENT MEASUREMENTS 1 inch = 2.54 cm 1 oz = 30 ml = 2 T 1 tsp = 5 ml 1 T = 15 ml = 3 tsp 1 glass = 8 ounces = 240 ml 1 cup = 8 ounces = 240 ml 1 teacup = 6 ounces = 180 ml 16 minims = 1 ml 2.2 lb = 1 kilogram KEY POINTS: Memorize the equivalent measurements for the metric and household systems of measurement. Working With Conversions Between Systems Fill in the blanks with the correct answer. 1. 1/2 oz = ml min = ml 2. 1 mcg = mg ml = t 3. 2 T = oz T = t mg = mcg cups = ml g = mg inch = cm g = mg cm = mm ml = oz kg = lb ml = tsp lb = kg mg = g dl = L 19 Copyright 2012, F. A. Davis Company

24 19. The doctor orders thyroxine 0.05 mg p.o. for the patient. Thyroxine is available in 25 mcg tablets. How many tablets will the nurse give? _ 20. The patient drinks two 6 oz cups of coffee for breakfast. How many ml did the patient drink? _ 21. A patient weighs 84 kg. How many pounds does the patient weigh? _ 22. Order: cephalexin 500 mg Available: cephalexin 0.25 gram per tablet How many tablets will the nurse give? _ 23. The physician orders Roxanol 30 mg p.o. q.3h. p.r.n. for pain for the patient. Roxanol is available in a bottle labeled 10 mg / 5 ml. How many tsp will the nurse administer? _ 24. The nurse has an order to administer 600 mcg of a drug subcut to the patient. The pharmacy sends an ampule labeled 2 mg / ml. How many ml will the nurse administer? _ 25. The nurse has an order to administer 75 mg of meperidine hydrochloride IM now. In the narcotic drawer, the nurse finds an ampule of meperidine hydrochloride labeled 100 mg / ml. How many ml will the nurse administer? _ 20 Copyright 2012, F. A. Davis Company

25 Module: INTAKE AND OUTPUT INTAKE AND OUTPUT: EQUIVALENT MEASUREMENTS 1 glass 8 ounces 240 ml 1 cup 8 ounces 240 ml 1 teacup 6 ounces 180 ml 1 styrofoam cup 6 ounces 180 ml 1 popsicle 3 ounces 90 ml ice cubes (melt to 1/2 the original volume) 1 ounce (oz) 30 ml 1 tablespoon (T, Tbs) 15 ml 1 teaspoon (t, tsp) 5 ml KEY POINTS: Intake and output (I & O) are calculated in ml. The size of food containers varies, so it is important for the nurse to become familiar with the specific containers used in each clinical setting. Parenteral intake is calculated as a part of the total intake. Working With Intake and Output Add the following intakes and outputs. 1. The patient is on strict I & O. For breakfast, the patient took 1 cup of coffee, a 4 ounce glass of juice, and 240 ml of milk. For lunch, the patient had a Styrofoam cup of tea and 6 ounces of broth. The patient voided 260 ml at 1000 and 180 ml at Calculate the patient s I & O. I O 21 Copyright 2012, F. A. Davis Company

26 2. The patient is NPO for breakfast. For lunch, the patient was allowed to take 120 ml of water. The patient vomited 180 ml at 1300 and voided 100 ml at At 1400, the patient took 2 T of gelatin and 1/2 glass of apple juice. Calculate the patient s I & O. I O 3. The patient has an NG tube connected to low wall suction. At 0930, the MD wrote an order to clamp the NG tube. The nurse emptied 280 ml of NG drainage. At 1100, the patient vomited 325 ml of bile-colored drainage. The NG tube was reconnected to suction and drained an additional 475 ml by the end of the shift. The patient s wound drainage tube collected 60 ml of serosanguineous fluid. The patient s indwelling urinary catheter drained 270 ml of dark amber urine. Calculate the patient s output. O 4. A patient who had prostate surgery yesterday has an indwelling urinary catheter with a continuous bladder irrigation. He is NPO for breakfast and is started on a clear liquid diet for lunch. He took 6 ounces of broth and 4 ounces of cranberry juice. By the end of the shift, the nurse calculates that 2000 ml of bladder irrigant has infused. The total amount emptied from the urinary bag was 2270 ml. Calculate the I & O. I O 22 Copyright 2012, F. A. Davis Company

27 5. The patient has an IV of D5W infusing at 125 ml / hr. For breakfast, the patient took 1 glass of juice and a cup of coffee. For lunch, the patient took 6 ounces of soup and a 12 ounce can of soda. The patient voided 220 ml at 1000 and 375 ml at Calculate the patient s 8 hr total I & O. I O 6. At 0700, the patient is NPO and has a primary IV of 1 L of D5NS q.10h. infusing continuously. The patient receives gentamicin 80 mg IVPB in 100 ml NS at , and metronidazole 500 mg in 100 ml NS at Calculate the patient s total parenteral intake starting at 0700 and ending at I 7. At 0700, the nurse started an IV of 1 L LR and set the infusion pump at 83 ml / hr. The patient was put on strict I & O. The patient was started on famotidine 20 mg IVPB in 50 ml NS, at 0800 and For breakfast, the patient took 1 cup of coffee and a 6 ounce bowl of cream of wheat. He was NPO except for ice chips for the rest of the shift. The patient took 6 ounces of ice chips and voided 425 ml. Calculate the patient s total I & O starting at 0700 and ending at I O 23 Copyright 2012, F. A. Davis Company

28 8. At 1500, the patient had an IV of 1 L of D5W infusing at 125 ml / hr. For dinner, the patient took 1 glass of juice and an 8 ounce can of nutritional supplement. The IV infiltrated at 1800 and was restarted at The patient received KCl 20 meq IVPB in 100 ml D5W at The patient voided twice for the entire shift (315 ml and 290 ml). Calculate the patient s total I & O starting at 1500 and ending at I O 9. At 2300, the patient had an IV of 1 L of 0.45% NS infusing at 50 ml / hr. The patient had coffee-ground emesis measuring 480 ml at The MD ordered 2 units of PRBCs over 3 hours, followed by an IV of 0.9% NS, to infuse at 150 ml / hr. The nurse discontinued the current IV and started the first unit of PRBC (250 ml) at 0200 and the second unit (270 ml) at The IV of 0.9% NS was started at Calculate the patient s total I & O starting at 2300 and ending at I O 10. At 1500, the patient had 900 ml left in the IV bag. The IV was infusing at 75 ml / hr. At 1900, the IV infiltrated and was restarted 1 hour later. The physician increased the IV rate to 125 ml / hr at Calculate the patient s total parenteral intake starting at 1500 and ending at I 24 Copyright 2012, F. A. Davis Company

29 11. At 0700, the MD ordered 1 L of D5/0.45% NS to infuse at 75 ml / hr for the first 3 hours, and then at 125 ml continuously. For breakfast, the patient took 1 cup of coffee, 8 ounces of milk, and 6 ounces of orange juice. The patient voided 50 ml at 0900 and 75 ml at At 1100, the nurse inserted a Foley catheter per MD order and obtained 425 ml of urine. For lunch, the patient only took 5 ounces of broth. The nurse emptied the Foley catheter at 1500 and obtained 250 ml. Calculate the patient s total I & O starting at 0700 and ending at I O 12. At 0900, the nurse begins the care of a patient who has just been transferred from the post anesthesia care unit. The patient has a new liter of D5/0.9% NS infusing at 125 ml / hr. The patient has an indwelling urinary catheter with continuous bladder irrigation of NS infusing at 75 ml per hour, to keep the catheter free of clots. At 1500, the nurse empties 1575 ml from the urinary catheter. Calculate the patient s total I & O starting at 0900 and ending at I O 13. At 2300, the patient had 850 ml left in the IV bag. The IV was infusing at 50 ml / hr. At 0200, the IV infiltrated and was restarted 2 hours later. The physician increased the IV rate to 75 ml / hr at Calculate the patient s total parenteral intake starting at 2300 and ending at I 25 Copyright 2012, F. A. Davis Company

30 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Intake and Output Read each situation, and then make a clinical judgment. Provide a rationale for your decision or action. SITUATION: The evening shift nurse learns during the hand-off change of shift report that the assigned patient is NPO, has a primary IV that has infused continuously all shift at 75 ml / hr, and received KCl 20 meq in 100 ml NS at 0900 and In reviewing the patient s documented intake and output from the day shift, the evening nurse is most correct to: 3-11 Intake and Output Oral IV Urine Emesis Other 7-3 NPO Total ml a. question the recorded 100 ml urine output. c. question the administration of the IVPBs. b. recalculate the primary IV intake. d. plan to administer an IVPB of KCl. Rationale / Discussion: 26 Copyright 2012, F. A. Davis Company

31 NASOGASTRIC TUBE FEEDING PROBLEMS KEY POINTS: Preparing diluted tube feedings requires calculating the number of ml of water to add to the formula to make the ordered strength. Information needed to solve the problem includes the amount of formula in the can and the ordered strength. Working With Nasogastric Tube Feeding Problems 1. The doctor orders a 3/4 strength formula tube feeding for the patient. The formula comes in cans containing 240 ml. How much water will the nurse add to the can of formula to make the ordered 3/4 strength diluted tube feeding? 2. The patient receives a 1/3 strength formula tube feeding. The formula can contains 233 ml. How much water will the nurse add to the can to make the 1/3 strength diluted tube feeding? 3. The order is to prepare a 2/3 strength tube feeding of Nepro for a patient with a percutaneous endoscopic gastrostomy (PEG) tube. How much water will the nurse add to the 237 ml can of Nepro to make a 2/3 strength tube feeding? 27 Copyright 2012, F. A. Davis Company

32 4. The physician orders 200 ml of a 1/4 strength tube feeding q.6h. for a patient with an NG tube. The formula can contains 250 ml. How much water will the nurse add to make the 1/4 strength tube feeding? 5. A patient who has been receiving full strength Jevity Plus PEG tube feedings develops diarrhea. The physician orders a diluted tube feeding of 1/2 strength Jevity Plus for the patient. How much water will the nurse add to the 237 ml can of Jevity Plus to make a 1/2 strength tube feeding? 6. The physician orders a 1/4 strength tube feeding of Osmolite at 40 ml / hr for a patient with an NG tube. The Osmolite can contains 237 ml. How much water will the nurse add to make a 1/4 strength tube feeding? 7. A patient has an order for 1/2 strength Pulmocare tube feedings, at 50 ml / hr through a PEG tube. The nurse prepares the dilute formula and has a total volume of 475 ml. According to hospital policy, only 4 hours of tube feeding formula can be hung at a time, to minimize bacterial growth. How many ml of the prepared 1/2 strength formula will the nurse use? 28 Copyright 2012, F. A. Davis Company

33 8. The physician orders a 250 ml bolus NG tube feeding of 3/4 strength q.8h. The formula can contains 237 ml. How much water will the nurse add to make the 3/4 strength tube feeding? 9. The physician orders a diluted tube feeding of 1/3 strength Jevity Plus for the patient. How much water will the nurse add to the 250 ml can of Jevity Plus to make a 1/3 strength tube feeding? 10. The physician orders a 2/3 strength tube feeding of Suplena at 25 ml / hr for a patient with an NG tube. The Suplena can contains 240 ml. How much water will the nurse add to make a 2/3 strength tube feeding? 29 Copyright 2012, F. A. Davis Company

34 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Nasogastric Tube Feedings Read each situation, and then make a clinical judgment. Provide a rationale for your decision or action. SITUATION: The nurse adds 80 ml of water to 200 ml Jevity formula. The formula tube feeding is started to 0900 at the ordered rate. The patient has a primary IV of NS 0.9% infusing at 80 ml for the 8 hr shift. The nurse emptied 575 ml of urine at 1500, the end of the shift. Which nursing action requires follow up? Date Physician's Orders Intake and Output 2/12 Start NG tube feeding of Jevity 2/3 strength at 50 ml per hour. 7-3 Total ml Oral IV NG Urine Emesis Foley Patient B ID ******* a. The documented NG tube intake should be 400 ml. c. The IV intake is incorrect for the ordered rate. b. The amount of water added to dilute the formula. d. The formula strength should be questioned. Rationale / Discussion: 30 Copyright 2012, F. A. Davis Company

35 Module: READING MEDICATION LABELS READING MEDICATION LABELS KEY POINTS: The essential information found on medication labels includes the following: trade name generic name dosage strength form of the drug route of administration expiration date instructions for mixing recommended dose The useful information found on medication labels includes the following: total quantity manufacturer's name storage information lot number controlled substance symbol Working With Reading Medication Labels Use the medication labels to fill in the answers. 1. a. Trade name b. Generic name c. Dosage strength d. Form of the drug e. Route of administration 31 Copyright 2012, F. A. Davis Company

36 2. a. Generic name b. Dosage strength c. Form of the drug d. Routes of administration e. Controlled substance? yes no f. Multidose Single-dose g. Ordered: 2.8 mg IV. The nurse will give 3. a. Trade name b. Generic name c. Instructions for mixing 32 Copyright 2012, F. A. Davis Company

37 4. a. Generic name b. Dosage strength c. Total quantity d. Routes of administration e. Controlled substance? yes no f. Single-dose vial? yes no g. Ordered: Morphine sulfate 12 mg IV. The nurse will give 33 Copyright 2012, F. A. Davis Company

38 5. Ordered: Augmentin 375 mg p.o. B.I.D. The nurse will give 6. a. Generic name b. Dosage strength c. Routes of administration d. Controlled substance? yes no e. Single-dose vial? yes no 34 Copyright 2012, F. A. Davis Company

39 f. Ordered: Haloperidol 2.5 mg IM. The nurse will give 7. a. Trade name b. Dosage strength c. Route of administration d. Storage information 8. a. Dosage strength b. Routes of administration c. Controlled substance? yes no 35 Copyright 2012, F. A. Davis Company

40 d. Ordered: Enalaprilat mg IV. The nurse will give 9. a. Dosage strength 10. a. Trade name b. Units per ml 36 Copyright 2012, F. A. Davis Company

41 11. a. Trade name b. Ordered: Novolog 6 units subcut now. The nurse will give 12. a. Trade name b. Ordered: Novolin 70/30, 22 units subcut now. The nurse will give 37 Copyright 2012, F. A. Davis Company

42 13. a. Trade name b. Ordered: Humalog 50/50, 17 units subcut q.am. The nurse will give 14. Check the information that is found on the medication label. Trade name Dosage strength Route of administration Storage information Generic name Form of the drug Controlled substance Total amount 38 Copyright 2012, F. A. Davis Company

43 15. Check the information that is found on the medication label. Trade name Dosage strength Route of administration Storage information Generic name Form of the drug Controlled substance Total amount 39 Copyright 2012, F. A. Davis Company

44 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Reading Medication Labels Read each situation, and then make a clinical judgment. Provide a rationale for your decision or action. SITUATION: The nurse has an order to administer morphine 3 mg IV stat. The nurse selects the following vial. In preparing to administer the ordered dose, it is most important for the nurse to: a. give 1.5 ml of the drug using two vials. c. research the appropriate route of administration. b. call the pharmacist to double check the order. d. not administer this drug. Rationale / Discussion: 40 Copyright 2012, F. A. Davis Company

45 Module: ORAL MEDICATIONS ORAL MEDICATIONS KEY POINTS: In setting up oral medication problems, be sure that the units in the medication order and the available drug match. Use a conversion table to convert unlike units of measurement. When you arrive at the answer, ask yourself if the answer is realistic. Nurses generally administer only 1-2 tablets, and less than 30 ml of medication, per dose. Working With Oral Medications Solve the following problems using the method of your choice. 1. The physician prescribed 0.8 mg of folic acid q.am. The pharmacy sends 0.4 mg tablets. How many tablets will the nurse give? 2. Lanoxin mg is ordered stat. The pharmacy sends 0.25 mg tablets of Lanoxin. How many tablets will the nurse administer? 3. Levothyroxine 0.1 mg is ordered daily. The pharmacy sends 50 mcg tablets. How many tablets will the nurse give? 41 Copyright 2012, F. A. Davis Company

46 4. The doctor orders Ceftin tablets 0.5 g p.o. for a patient. How many tablets will the nurse give? 5. The order is for Dilantin 0.1 g p.o. daily. How many tablets will the nurse give to the patient? 6. Aluminum hydroxide suspension 15 ml is ordered q.i.d. The pharmacy sends a bottle of aluminum hydroxide labeled 320 mg / 5 ml. How many mg is the patient receiving per dose? 42 Copyright 2012, F. A. Davis Company

47 7. The patient receives furosemide 80 mg p.o. b.i.d. The pharmacy sends furosemide oral solution labeled 10 mg / ml. How many ml will the nurse give per dose? 8. The nurse is instructing a patient to take Diflucan 100 mg oral suspension at home. How many tsp will the nurse instruct the patient to take per dose? 9. Diphenhydramine hydrochloride elixir 50 mg p.o. p.r.n. is ordered for itching. Diphenhydramine hydrochloride elixir 12.5 mg / 5 ml is available. How many ml will the nurse give? 10. The order is for atropine 400 mcg tab i p.o. 30 minutes before surgery. The pharmacy sends atropine 0.4 mg tablets. How many tablets will the nurse give? 43 Copyright 2012, F. A. Davis Company

48 11. The nurse practitioner orders nystatin 200,000 units p.o. q.i.d. swish and swallow. The pharmacy sends nystatin 100,000 units / 5 ml. How many ml will the nurse give? 12. Nitroglycerin extended-release tablets 5 mg is ordered q.12h. p.o. The pharmacy sends nitroglycerin tablets labeled 2.5 mg / tablet. How many tablets will the nurse give? 13. Augmentin oral suspension 250 mg q.6h. is ordered for a patient upon discharge. The pharmacy sends the following bottle. How many days will this bottle last? 14. The doctor orders enalapril gram p.o. daily. Enalapril is available in 5 mg scored tablets. How many tablets will the nurse give? 44 Copyright 2012, F. A. Davis Company

49 15. The order is for cyanocobalamin 1 mg p.o. daily. The pharmacy sends cyanocobalamin 1000 mcg tablets. How many tablets will the nurse give? 16. The patient is to receive 20 meq of KCl p.o. q.am. The pharmacy sends a bottle labeled 30 meq / 15 ml. How many ml will the nurse administer? 17. Erythromycin oral suspension 500 mg q.6h. is ordered for a patient. Erythromycin is available in 200 mg / 5 ml. How many ml will the nurse administer? 18. Carvedilol 12.5 mg p.o. b.i.d. is ordered for the patient. In the patient s medication drawer, the nurse finds the following unit dose tablets. The nurse is most correct to administer: Carvedilol mg Carvedilol 6.25 mg (4 tablets available) (2 tablets available) 19. Morphine sulfate oral solution, 120 mg q.4h. around the clock, is ordered for a patient in hospice care. Morphine sulfate is available in 100 mg / 5 ml. How many mg of morphine sulfate will the patient receive per day? 45 Copyright 2012, F. A. Davis Company

50 20. Ceclor oral suspension 375 mg q.8h. is ordered for a patient on discharge. The patient has a prescription for Ceclor 125 mg / 5 ml oral suspension. How many tablespoons will the nurse instruct the patient to take per dose? 21. Mirapex 1500 mg is ordered t.i.d. for a patient. The nurse has Mirapex 0.5 g tablets. How many tablets will the nurse administer for the morning dose? 22. The patient has an order for levetiracetam oral solution 3 g daily. The patient has a bottle of levetiracetam oral solution 100 mg / ml. How many ml will the nurse administer to the patient? 23. The doctor orders furosemide 40 mg oral solution p.o. q.am. Furosemide 8 mg / ml oral solution is available. The nurse has a medicine cup with ounce measurements. How many teaspoons will the nurse administer to the patient? 24. The nurse is preparing to administer the 0900 medications to a patient. In the medication drawer, the nurse finds the following unit dose tablets: digoxin 0.25 mg scored tablets, Captopril 12.5 mg tablets, furosemide 10 mg tablets, Cipro 500 mg tablets. How many tablets of each of the medications will the nurse administer at 0900? Digoxin mg p.o. q.am 0900 Captopril 12.5 mg p.o. q.12h Furosemide 20 mg p.o Cipro 0.5 g p.o. q.12h Copyright 2012, F. A. Davis Company

51 25. Calcitriol capsule 1 mcg p.o. q.am is ordered for the patient. How many capsules will the nurse administer? 26. Cimetidine 450 mg at bedtime is ordered for the patient. The nurse has available the following bottle. How many ml will the nurse administer? 47 Copyright 2012, F. A. Davis Company

52 27. The patient has an order for aspirin 1 g p.o. q.6h. p.r.n. for headache. How many caplet(s) will the nurse administer? 28. Warfarin 5 mg p.o. is ordered for the patient this morning. How many tablet(s) will the nurse administer? 48 Copyright 2012, F. A. Davis Company

53 29. The order is for cefprozil 0.25 g b.i.d. How much water will be added to prepare the suspension? a. How many tsp will the nurse administer? b. 30. The order is for fluconazole 100 mg p.o. now. How much water will be added to prepare the suspension? a. How many tsp will the nurse administer? b. 49 Copyright 2012, F. A. Davis Company

54 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Oral Medications Read each situation, and then make a clinical judgment. Provide a rationale for your decision or action. Hydralazine 25 mg p.o K-Dur 16 meq p.o Propranolol 60 mg p.o K-Dur 8 meq K-Dur 8 meq Propranolol 60 mg ER Hydralazine 25 mg SITUATION: The nurse is preparing the 0900 medications and finds the patient s unit dose medications in the medication drawer. Which action(s) by the nurse are most appropriate (select all that apply)? a. Give all the 0900 medications. b. Call the pharmacist regarding the propranolol. d. Give the hydralazine and the K-Dur at e. Give the hydralazine and propranolol at c. Call the pharmacist regarding the K-Dur. Rationale / Discussion: 50 Copyright 2012, F. A. Davis Company

55 Module: SYRINGES AND NEEDLES SYRINGES KEY POINTS: The most commonly used syringe, the 3 ml syringe, is calibrated to measure 0.1 ml accurately. Most 3 ml syringes have both minim and ml scales. The TB syringe measures volumes of 1 ml or less and is calibrated to measure 0.01 ml accurately. The TB syringe has minim and ml scales. Larger volume syringes are calibrated in 0.2 ml or 1 ml increments. Insulin is measured in units and is drawn up in an insulin syringe. The standard insulin syringe is calibrated by 2 unit increments. Low dosage insulin syringes are calibrated in 1 unit increments. Working With Syringes Shade in the syringe with the indicated amount of medication ml 1/ / / ml m ml 51 Copyright 2012, F. A. Davis Company

56 ml m ml minims m ml minims m ml ml ml 1/ / /2 1/ / / ml m ml 52 Copyright 2012, F. A. Davis Company

57 ml ml units of insulin units of insulin units of insulin units of insulin units of insulin / / / USE U-100 INSULIN USE U-100 INSULIN USE U-100 INSULIN USE U-100 INSULIN USE U-100 INSULIN ml UNITS UNITS 100 UNITS 50 UNITS 50 UNITS 53 Copyright 2012, F. A. Davis Company

58 units of insulin USE U-100 INSULIN UNITS units of insulin USE U-100 INSULIN ml The nurse receives a vial of Enalaprilat from the pharmacy. The order is to administer mg of Enalaprilat IV. Shade in the ml that will be administered to the patient. 1/ / ml 100 UNITS 2 1/2 20. The nurse has an order to administer Glycopyrrolate 150 mcg IV. Available is Glycopyrrolate 0.4 mg / 2 ml. Shade in the amount of Glycopyrrolate that will be administered to the patient m ml 54 Copyright 2012, F. A. Davis Company

59 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Syringes Read each situation, and then make a clinical judgment. Provide a rationale for your decision or action. SITUATION: After calculating the ordered dose of a medication, the nurse determines that the patient is to receive 5 ml of the medication IM. The nurse selects a 5 ml syringe to administer the ordered dose. The nurse: a. has correctly determined the most appropriate syringe to measure and administer this dose accurately. b. needs to contact the physician and request a higher dosage strength of the medication. c. needs to contact the pharmacist to ensure that the ordered dose has been correctly calculated. d. should divide the medication into two injections, using two 3 ml syringes. Rationale / Discussion: 55 Copyright 2012, F. A. Davis Company

60 NEEDLES KEY POINTS: Needles are identified by two numbers: length and gauge. Needle length is measured in inches. Needle gauge refers to the diameter. The larger the number of the gauge, the smaller the diameter of the needle. Needles are packaged in standard sizes with syringes for IM, ID, subcut, and IV use. Working With Needles Choose the correct needle size for the following injections. 1. A subcut injection of insulin 2. An IM injection 3. A TB skin test 4. An IM injection for an obese person 5. A subcut injection into the upper arm 6. Drawing up viscous medication from a vial 56 Copyright 2012, F. A. Davis Company

61 Choose the correct syringe and needle for the following injections. Fill in the syringe. 1. Meperidine 75 mg (1 ml) IM a m 21G ml b. 22G 1 1/2 1/ / /2 2. Filgrastim 300 mcg (1 ml) subcut a m 28G 3/ ml b. 25G 5/8 1/ / /2 3. Heparin 5000 units (0.67 ml) subcut 25G 5/8 a m ml b. 28G 1/ USE U-100 INSULIN UNITS 57 Copyright 2012, F. A. Davis Company

62 4. Hepatitis A vaccine 1 ml IM a ml 18G 1/2 b. 23G 1 1/2 1/ / /2 5. Ketorolac 60 mg (2 ml) IM a m 21G 1 1/ ml b. 22G 1 1/2 1/ / /2 6. Humulin Regular insulin 17 units subcut a. 28G 1/ USE U-100 INSULIN UNITS b. 28G 1/ USE U-100 INSULIN UNITS 58 Copyright 2012, F. A. Davis Company

63 7. Humulin Regular insulin 6 units and Humulin NPH insulin 13 units subcut a. 28G 1/2 5 USE U-100 INSULIN UNITS b. 28G 1/ USE U-100 INSULIN UNITS 8. Heparin 1000 units (0.1 ml) subcut a m 25G 5/ ml b. 25G 5/8 1/ / /2 9. Morphine sulfate 10 mg (16 minims) subcut a m 21G ml b m 25G 1/ ml 59 Copyright 2012, F. A. Davis Company

64 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Needles Read each situation, and then make a clinical judgment. Provide a rationale for your decision or action. Date 7/29 Medication Record Heparin 5000 units subcut into the abdomen q.am 0900 SITUATION: To administer this medication safely, it is most correct for the nurse to use a: a. 18G 1 Patient T b. c. 20G 1 1/2 22G 1 d. 25G 1/2 Rationale / Discussion: 60 Copyright 2012, F. A. Davis Company

65 Module: PARENTERAL MEDICATIONS PARENTERAL MEDICATIONS KEY POINTS: In setting up parenteral medication problems, be sure that the units in the medication order and the available drug are the same. Use a conversion table to convert unlike units of measurement. When you arrive at the answer, ask yourself if the answer is realistic. Nurses generally administer 3 ml or less of a parenteral medication. With insulin, just draw up the total units ordered. Working With Parenteral Medications Use the method of your choice to solve the problems. 1. The physician prescribed 0.1 mg of folic acid IM. The pharmacy sends the following ampule. How many ml will the nurse give? Folic Acid 0.5 mg / ml 2. Meperidine HCl 75 mg is ordered stat. Meperidine HCl 50 mg / ml is available. How many ml will the nurse administer? 61 Copyright 2012, F. A. Davis Company

66 3. Heparin sodium 5000 units subcut q.12h. is ordered for a patient. The pharmacy sends a vial labeled heparin sodium 20,000 units / ml. How many ml will the nurse give? 4. Procaine penicillin G 1.2 million units IM is ordered for a patient. The pharmacy sends procaine penicillin G 600,000 units / ml. How many ml will the nurse give? Fill in the syringe. 5. The preoperative order is morphine sulfate 9 mg with glycopyrrolate 0.08 mg IM stat. Morphine sulfate 15 mg / ml and glycopyrrolate 200 mcg / ml are available in the medication drawer. Calculate the preoperative medications. Morphine sulfate: Glycopyrrolate: Fill in the syringe with the total amount. 1/ / /2 1/ / /2 62 Copyright 2012, F. A. Davis Company

67 6. Hydromorphone 1 mg subcut q.3h. p.r.n. for pain is ordered for a patient. Hydromorphone 10 mg / ml is available in the narcotic drawer. How many ml will the nurse give? Fill in the ordered dose in each syringe m ml 1/ / /2 7. The order is for atropine 400 mcg subcut now. The pharmacy sends the following multidose vial. How many ml will the nurse give? 8. The physician orders morphine sulfate gram. Morphine sulfate is available in 15 mg / ml How many minims will the nurse give? Fill in the syringe m ml 63 Copyright 2012, F. A. Davis Company

68 9. Epoetin 12,000 units subcut 3 x / week is ordered. The pharmacy sends a vial of epoetin labeled 20,000 units / ml. How many ml will the nurse give? Fill in the ordered dose in each syringe m ml 10. The doctor orders ampicillin 250 mg. The pharmacy sends a vial of ampicillin labeled 1 g / ml. How many ml will the nurse give? Fill in the ordered dose in the most appropriate syringe. 1/ / /2 1/ / / m ml 11. The physician orders phenytoin 125 mg IM. The nurse prepares to draw up the medication from a vial labeled phenytoin 50 mg / ml. How many ml will the nurse give? 64 Copyright 2012, F. A. Davis Company

69 12. Humulin NPH insulin 23 units q.am is ordered for a patient. How much insulin will the nurse give? Fill in the most appropriate syringe. USE U-100 INSULIN UNITS USE U-100 INSULIN UNITS 13. Humulin N insulin 35 units and Humulin R insulin 7 units q.am are ordered for a patient. How much insulin will the nurse give? Fill in the most appropriate syringe. USE U-100 INSULIN UNITS UNITS USE U-100 INSULIN 14. Humulin 70/30 insulin 21 units q.am is ordered for the patient. How much insulin will the nurse give? Fill in the most appropriate syringe. USE U-100 INSULIN UNITS UNITS USE U-100 INSULIN 65 Copyright 2012, F. A. Davis Company

70 15. Humulin 50/50 insulin 19 units q.am is ordered for the patient. How much insulin will the nurse give? Fill in the most appropriate syringe. USE U-100 INSULIN UNITS USE U-100 INSULIN UNITS 16. Humulin R insulin 2 units is ordered for the patient. How much insulin will the nurse give? Fill in the most appropriate syringe. USE U-100 INSULIN 17. Humulin NPH insulin 22 units and Humulin Regular insulin 7 units are ordered stat. How much insulin will the nurse give? Fill in the most appropriate syringe UNITS UNITS UNITS UNITS USE U-100 INSULIN USE U-100 INSULIN USE U-100 INSULIN 66 Copyright 2012, F. A. Davis Company

71 18. Adenosine 2.7 mg IV is ordered. The pharmacy sends a 2 ml single-dose vial of adenosine. How many ml will the nurse administer? 19. Heparin 4500 units subcut is ordered. The nurse has the following vial of heparin. How many ml will the nurse administer? 20. The nurse receives an order to administer ranitidine 20 mg IVP. How many ml will the nurse administer? 67 Copyright 2012, F. A. Davis Company

72 21. Cyanocobalamin 0.5 mg is ordered subcut. To carry out this order correctly, the nurse will administer how many ml of cyanocobalamin? 22. The physician orders amikacin 0.25 g IM q.12h. How many ml will the nurse administer per dose? 23. Enalaprilat mg IVP q.6h. is ordered. After drawing up the ordered dose, how many ml will the nurse discard from the vial? 68 Copyright 2012, F. A. Davis Company

73 24. The MD orders granisetron 2000 mcg direct IV 30 minutes prior to chemotherapy. Pharmacy sends the following vial. How many ml will the nurse administer to the patient? 25. Adenosine 9 mg is ordered direct IV stat for the patient. Pharmacy sends the following vial. How many ml will the nurse administer? 26. Enoxaparin 150 mg / 1 ml prefilled syringe is available. The nurse has an order for enoxaparin 90 mg subcut. How many minims will the nurse administer? 27. The nurse has a 5 ml multidose vial of heparin labeled 20,000 units per ml. The order is to administer 15,000 units of heparin subcut to the patient q.12h. How many ml will the nurse administer? Fill in the syringe m ml 69 Copyright 2012, F. A. Davis Company

74 28. The patient has an order for metoclopramide 5 mg IM stat. The pharmacy sends a single-dose vial of metoclopramide. How many ml will the nurse administer to the patient? 29. The physician writes an order for terbutaline 250 mcg subcut for the patient who is wheezing. The nurse has the following vial of terbutaline. How many ml will the nurse administer to the patient? 30. The patient has an order for morphine sulfate 1.5 mg direct IV injection. How many ml will the nurse administer to the patient? 70 Copyright 2012, F. A. Davis Company

75 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Parenteral Medications Read each situation, and then make a clinical judgment. Provide a rationale for your decision or action. SITUATION: The nurse has an order to administer levothyroxine mg IVP q.am. How many ml will the nurse draw into the syringe? a ml c. 1.5 ml b ml d ml Rationale / Discussion: 71 Copyright 2012, F. A. Davis Company

76 Module: RECONSTITUTION OF POWDERED MEDICATIONS SINGLE-STRENGTH RECONSTITUTION KEY POINTS: In single-strength reconstitution, the manufacturer identifies one amount of diluent to add to the powdered medication. The dosage strength of the mixed medication is used to calculate the amount to give to the patient. Information needed to work with single-strength reconstitution problems includes the type and amount of diluent, dosage strength of the mixed medication, length of time the solution will remain stable, and storage information. Once the medication is reconstituted, the nurse writes the date and time of reconstitution and the nurse s initials on the medication label. Working With Single-Strength Reconstitution Solve the following single-strength reconstitution problems. 1. The physician orders cefazolin sodium 0.25 g IM q.8h. The pharmacy sends a 1 g vial of sterile cefazolin powder with the following mixing instructions: For IM use, add 2.5 ml sterile water for injection and shake. Provides a volume of 3.0 ml (330 mg / ml). a. How much diluent will be added to the cefazolin sodium powder? 72 Copyright 2012, F. A. Davis Company

77 b. What type of diluent will be added? c. What is the dosage strength of the mixed medication? d. How many ml of the medication will the nurse give to the patient? 2. The order is for procaine penicillin G 300,000 units IM b.i.d. A 1 gram vial of procaine penicillin G powder is in the medication drawer. The medication has the following mixing instructions: IM use: Dissolve 4.6 ml bacteriostatic water for injection to make 200,000 units / ml. a. How much diluent will be added to the procaine penicillin G powder? b. What type of diluent will be added? c. What is the dosage strength of the mixed medication? d. How many ml of the medication will the nurse give to the patient? 73 Copyright 2012, F. A. Davis Company

78 3. What data should be entered on the vial below when labeling the vial after reconstitution? Procaine Penicillin G 1 g 4. The physician orders 200 mg of an antibiotic IM q.12h. The pharmacy sends a vial of antibiotic powder for reconstitution with the following mixing directions: For IM injection, IV direct (bolus) injection, or IV infusion, add 2 ml sterile water for injection. Shake well. Provides an approximate concentration of 125 mg / ml. a. How much diluent will be added to the antibiotic powder? b. What type of diluent will be added? c. What is the dosage strength of the mixed medication? d. How many ml of the medication will the nurse give to the patient? 74 Copyright 2012, F. A. Davis Company

79 5. The order is for ticarcillin disodium 0.5 g IM q.6h. The directions state to add 2 ml of NS. The reconstituted solution contains 1 g / 2.6 ml. a. What is the dosage strength of the reconstituted medication? b. How much will be given to the patient? 6. The order is for cefazolin 450 mg IM q.6h. a. How much diluent will be added to the cefazolin powder? b. What type of diluent will be added? 75 Copyright 2012, F. A. Davis Company

80 c. What is the resulting dosage strength of the mixed medication? d. How many ml of the cefazolin will the nurse give to the patient? 7. The physician orders Bacitracin 6000 units IM. q.am. The pharmacy sends the following drug: a. How much diluent will be added to the Bacitracin for injection powder? b. What is the dosage strength of the mixed medication? c. How many ml of the Bacitracin for injection will the nurse give to the patient? 76 Copyright 2012, F. A. Davis Company

81 d. What data should be entered on the label above after reconstitution? 8. The order is for 0.5 g IV of a drug. Reconstitution instructions for the powdered medication include: Reconstitute with 2 ml bacteriostatic water (with benzyl alcohol) for injection. Resulting dosage strength is 300 mg / ml. How many ml will the nurse give? 77 Copyright 2012, F. A. Davis Company

82 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Single-Strength Reconstitution Read each situation, and then make a clinical judgment. Provide a rationale for your decision or action. SITUATION: The nurse has an order to administer 250 mg of Augmentin. The nurse measures 1 tsp. Which action by the nurse is most correct? a. Convert the tsp to ml. c. Question the date of reconstitution. b. Administer the measured dose. d. Use a 3 ml syringe to measure the dose. Rationale / Discussion: 78 Copyright 2012, F. A. Davis Company

83 MULTIPLE-STRENGTH RECONSTITUTION KEY POINTS: In multiple-strength reconstitution, the manufacturer identifies several amounts of diluent to add to the powdered medication. The nurse must select one of the listed amounts of diluent. The dosage strength of the mixed medication is used to calculate the amount to give to the patient. Information needed to work with multiple-strength reconstitution problems includes the type and amount of diluent, dosage strength of the mixed medication, length of time the solution will remain stable, and storage information. Once the medication is reconstituted, the nurse circles the amount of diluent selected and the corresponding dosage strength. The date and time of reconstitution and the nurse s initials are also written on the medication label. Working With Multiple-Strength Reconstitution Solve the following multiple-strength reconstitution problems. 1. When preparing multiple-strength reconstitution medications, the nurse will make the most concentrated solution when adding: the largest volume of diluent. the smallest volume of diluent. 79 Copyright 2012, F. A. Davis Company

84 2. The physician orders cefoperazone 750 mg IV q.12h. The pharmacy sends a 2 g vial of sterile cefoperazone powder with the following mixing instructions: Diluent: sterile bacteriostatic water for injection. Add 10 ml for an approximate volume of 100 mg / ml. Add 6 ml for an approximate volume of 150 mg / ml. a. What is the dosage strength if the nurse chooses to add 10 ml of diluent? b. How many ml of the mixed solution will the nurse administer to the patient? c. What information should be written on the label of the reconstituted cefoperazone? 3. The physician orders penicillin G potassium 1 million units IV q.6h. The nurse has a vial with the following instructions: Add Diluent Dosage Strength (ml) of Mixed Medication ,000 units / ml ,000 units / ml ,000 units / ml a. What is the dosage strength if the nurse chooses to add 9.6 ml of diluent? 80 Copyright 2012, F. A. Davis Company

85 b. What is the dosage strength if the nurse chooses to add 1.6 ml of diluent? c. Select one volume of diluent, and calculate the amount of penicillin G potassium to administer. 4. The physician orders 750,000 units of penicillin G potassium. The nurse has the following vial: a. Select one volume of diluent. What is the dosage strength of the mixed medication if this volume of diluent is added to the vial? b. Calculate the amount of medication to administer. 81 Copyright 2012, F. A. Davis Company

86 c. How long is the solution stable if refrigerated? d. Complete the label with the correct information. 5. The physician orders ampicillin 700 mg IV q.6h. The nurse has a vial of powdered ampicillin with the following directions for reconstitution: For IM or IV use: Add bacteriostatic NS or sterile water for injection and shake. Diluent Strength of Mixed Medication 3.5 ml 500 mg / ml 7.2 ml 250 mg / ml Use within 1 hour of reconstitution. Stable under refrigeration for 6 hours. See package insert. a. Select one volume of diluent. What is the dosage strength of the mixed medication if this volume of diluent is added to the vial? b. Calculate the amount of medication to administer. c. How long is the mixed solution stable? d. If the ampicillin is given IM, which diluent volume would be preferable? Why? e. Complete the label with the appropriate information. 82 Copyright 2012, F. A. Davis Company

87 6. The physician orders Cefotaxime 500 mg IM q.12h. The nurse has a vial of powdered Cefotaxime with the following directions: a. After reading the label, the nurse can identify the (check all that apply): routes of administration. storage information. dosage strength. usual adult dosage. type of diluent. b. To administer the ordered dose (500 mg), the nurse: needs to call the pharmacist for mixing instructions. should read the accompanying literature. will give 2 ml of the reconstituted drug. 83 Copyright 2012, F. A. Davis Company

88 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Multiple-Strength Reconstitution Read each situation, and then make a clinical judgment. Provide a rationale for your decision or action. SITUATION: The order is to add 2.4 million units of penicillin G potassium to the IV bag. The nurse draws up 5 ml of penicillin G potassium. It is most appropriate for the nurse to: a. add the 5 ml to the IV bag. c. add 9.6 ml of penicillin G potassium to the IV bag. b. recalculate the dose. d. use 1,000,000 u / ml to calculate the desired dose. Rationale / Discussion: 84 Copyright 2012, F. A. Davis Company

89 Module: CALCULATIONS INFUSION RATES KEY POINTS: To set the rate of IV infusions by IV pump, the nurse needs to calculate the ml / hr of the infusion. To regulate the rate of IV infusions by gravity flow, the nurse needs to calculate the flow rate, or gtt / minute, of the infusion. To calculate the flow rate (gtt / min), the nurse needs the following information: the volume of IV fluid per hour and the drop factor of the IV tubing. Round all ml / hr and gtt / min to a whole number. Working With Milliliters per Hour Solve the following problems using the method of your choice. 1. The order is for 1000 ml D5/0.225% NS q.12h. How many ml / hr will the nurse set on the IV pump? 2. The order is for 1000 ml D5W q.16h. How many ml / hr will the nurse set on the IV pump? 3. The physician orders 3000 ml of Lactated Ringer s to infuse over 24 hours. How many ml will the patient receive per hour? 85 Copyright 2012, F. A. Davis Company

90 4. The order is to infuse 1 unit of packed red blood cells (250 ml) over 1 1/2 hours. Calculate the ml / hr. 5. The doctor orders ceftizoxime 1 g IVPB q.12h. The pharmacy sends ceftizoxime 1 g in 50 ml NS to infuse over 30 minutes. Calculate the ml / hr. 6. The physician orders 1 L 0.9% NS to infuse over 6 hours. Calculate the ml / hr. 7. The order is to infuse 500 ml of D5W over 10 hrs. Calculate the ml / hr. 8. The order is to infuse 1 unit of packed red blood cells (275 ml) over 2 hours. Calculate the ml / hr. 9. The physician orders 250 ml 0.9% NS to infuse over 2 1/2 hours. Calculate the ml / hr. 10. The doctor orders vancomycin 1 g IVPB q.12h. The pharmacy sends vancomycin 1 g in 200 ml 0.9% NS to infuse over 90 minutes. Calculate the ml / hr. 86 Copyright 2012, F. A. Davis Company

91 Working With Flow Rate 1. The nurse hangs up 1 L D5W to infuse over 8 hours. Use the following IV tubing label to calculate the flow rate. Primary IV Set Non-Vented, 72 inch 60 drops / ml 2. The physician orders 1 L of D5LR to infuse at 83 ml / hr. The IV tubing delivers 15 gtt / ml. What is the flow rate (gtt / min)? 3. The doctor orders 1 unit of whole blood (500 ml) to infuse over 4 hours. The blood tubing delivers 10 gtt / ml. What is the flow rate of the blood? 4. The order is for 500 ml of NS TKO (30 ml / hr). The nurse selects the following IV tubing. What is the flow rate? Primary IV Set Non-Vented, 72 inch 15 drops / ml 87 Copyright 2012, F. A. Davis Company

92 5. The IV is to infuse at 42 ml / hr. The drop factor on the IV tubing is 15 gtt / ml. What is the flow rate? 6. The order is to infuse 250 ml of NS over 1 1/2 hours. The drop factor is 12 gtt / ml. What is the flow rate? 7. The order is for 500 ml of D5/0.45% NS to infuse over 4 hours. The nurse selects the following IV tubing. What is the flow rate? Primary IV Set Non-Vented, 72 inch 15 drops / ml 8. The nurse is to infuse vancomycin 1 g in 250 ml 0.9% NS over 1 1/2 hours. The nurse selects a minidrop tubing (60 gtt / ml). Calculate the flow rate. 9. The patient is to receive 1 unit whole blood (475 ml) to infuse over 3 hours. The nurse starts the transfusion using blood tubing labeled 10 gtt / ml. What is the flow rate? 10. The nurse is to infuse 1 liter D10W over 8 hours. The nurse selects IV tubing label 12 gtt / ml. Calculate the flow rate. 88 Copyright 2012, F. A. Davis Company

93 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Milliliters per Hour and Flow Rate Read each situation, and then make a clinical judgment. Provide a rationale for your decision or action. Intake and Output 7-3 Oral Total ml 3-11 IV Urine Emesis Other Primary IV Set Non-Vented, 72 inch 15 drops / ml SITUATION: The nurse started an IV of 500 ml NS 0.9% at 0800, to infuse over 10 hours via gravity. The IV infused at 13 gtt / min all shift. At 1500, the end of the shift, the nurse completed the intake and output record. In reviewing the Intake and Output record, the nurse from the evening shift is most correct to: a. continue to monitor the IV at 13 gtt / min. c. increase the flow rate to 31 gtt / min. b. question the oral intake for the day shift. d. change the IV tubing to a minidrop. Rationale / Discussion: 89 Copyright 2012, F. A. Davis Company

94 DIRECT IV MEDICATION ADMINISTRATION KEY POINTS: Use drug reference information to find the rate of administration for direct IV administration of medications. If the dosage ordered is smaller than the recommended dose in the drug reference book, administer the dosage over the full amount of time recommended. The term fraction thereof in a drug reference book means that any fraction of a dose is given over the full amount of time recommended. Medications identified as High Alert require special attention in the preparation, administration, and follow-up care of the patient. Working With Direct IV Medication Administration Use the information provided to identify the rate for the administration of direct IV medications for the following problems. 1. The doctor orders morphine sulfate 10 mg IV push stat. The drug reference information for direct IV administration of morphine is: High Alert: Administer 2.5 mg - 15 mg over 5 min. What is the rate of administration for this dose? 2. The doctor orders hydromorphone 3 mg IV injection for severe pain. The drug reference literature states, Administer slowly at a rate not to exceed 2 mg over 3-5 min. High Alert: Rapid infusion may lead to increased respiratory depression, hypotension, and circulatory collapse. What is the rate of administration for this dose? 90 Copyright 2012, F. A. Davis Company

95 3. The doctor orders furosemide 80 mg direct IV injection now. What is the rate of administration for this dose? furosemide (fur-oh-se-mide) IMPLEMENTATION Direct IV: Administer undiluted. Rate: Administer at a rate of 20 mg / min. Intermittent Infusion: Dilute large doses. Rate: Not to exceed 4 mg / min. 4. The doctor orders glycopyrrolate 0.1 mg direct IV stat. The recommended rate for direct IV administration is 20 mcg over 1 minute. What is the rate of administration for the ordered dose? 5. The doctor orders diazepam 10 mg direct IV injection now. The drug reference information states, Administer slowly at a rate of 5 mg / min in adults. What is the rate of administration for this dose? 91 Copyright 2012, F. A. Davis Company

96 6. The doctor orders lorazepam gram IVP 30 minutes before chemotherapy. What is the rate of administration for this dose? lorazepam (lor-az-e-pam) IMPLEMENTATION Rate: Administer at a rate not to exceed 2 mg / min. Rapid IV administration may result in apnea, hypotension, bradycardia, or cardiac arrest. 7. The doctor orders phenytoin 75 mg direct IV administration for a patient experiencing status epilepticus. What is the rate of administration for this dose? phenytoin (fen-i-toyn) IMPLEMENTATION Direct IV: Administer undiluted. Administer at a rate not to exceed 50 mg over 1 minute in adults. Rapid administration may result in severe hypotension cardiovascular collapse, or CNS depression. 92 Copyright 2012, F. A. Davis Company

97 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Direct IV Medication Administration Read each situation, and then make a clinical judgment. Provide a rationale for your decision or action. Date 2/12 Physician s Orders Atropine 0.8 mg IVP stat atropine (at-ro-peen) IMPLEMENTATION Direct IV: Administer undiluted. Patient C ID ******* Rate: Administer over 1 min. Slow administration (over >1 min) may cause a paradoxical bradycardia (usually resolved in approximately 2 min). SITUATION: Atropine is available in 1 mg / ml. To implement this order safely, the nurse is most correct to: a. give the ordered dose slowly into the vein. b. administer 0.8 ml over 1 minute. c. add the atropine dose to the primary IV fluid. d. dilute with 10 ml normal saline. Rationale / Discussion: 93 Copyright 2012, F. A. Davis Company

98 INFUSION AND COMPLETION TIME KEY POINTS: Use ml / hr and total amount of IV fluid to calculate the infusion time (hours and minutes). Use the starting time and the infusion time to calculate the completion time of the IV fluid. With infusion time, convert parts of an hour to minutes. Working With Infusion Time Use the information provided to identify the infusion time for the following problems. 1. The doctor orders 1 L of D5/0.45 NS to infuse at 125 ml / hr. What is the infusion time of the IV? 2. At 0700, 500 ml of D5W is started to infuse at 60 ml / hr. What is the infusion time of the IV? 3. At 1000, 1000 ml of Lactated Ringer s is started on the patient. The IV is infusing at 75 ml / hr. The drop factor is 10 gtt / ml. What is the infusion time of the IV? 4. The nurse restarts an IV with 800 ml D5/LR to infuse at 125 ml / hr. What is the infusion time of the IV? 94 Copyright 2012, F. A. Davis Company

99 5. The patient has an IVPB of famotidine 20 mg in 100 ml NS. The nurse sets the IV pump at 200 ml / hr. What is the infusion time of the IVPB? 6. The nurse starts an IV of 100 ml D5W with 10 meq KCl to infuse at 30 ml / hr. What is the infusion time of the IV? Working With Completion Time 1. The nurse starts 1 L of D5/0.45% NS to infuse at 125 ml / hr at What is the completion time of this IV? 2. At 1400, 250 ml of D5W is started to infuse at 60 ml / hr. What is the completion time of the IV? 3. At 2000, 1000 ml of 0.45 NS is started to infuse at 100 ml / hr. What is the completion time of the IV? 4. The nurse restarts 600 ml of IV fluid at 1930 to infuse at 75 ml / hr. What is the completion time of the IV? 95 Copyright 2012, F. A. Davis Company

100 5. The nurse restarts an IV bag containing 500 ml of D5/0.45% NS at 1430, to infuse at 80 ml / hr. What is the completion time of this IV? 6. The nurse restarts 750 ml of LR at 0900, to infuse at 150 ml / hr. What is the completion time of the IV? Working With Infusion and Completion Time 1. The doctor orders 1 L NS to infuse over 10 hours. The nurse starts the IV at At 1000 the patient pulls out the IV. The nurse restarts the IV at 1100 at the same rate. Starting with the amount of IV fluid left at 1100, calculate the new infusion time and the completion time of the IV. Infusion time Completion time 2. The doctor orders 500 ml D10W to infuse at 75 ml / hr. The nurse starts the IV at At 1530, the IV rate is increased to 100 ml / hr, per doctor's orders. Starting with the amount of IV fluid remaining at 1530, calculate the new infusion time and completion time of the IV. Infusion time Completion time 96 Copyright 2012, F. A. Davis Company

101 3. The doctor orders 1 L NS to infuse over 8 hours. The nurse starts the IV at At 2000, the IV rate is decreased to 100 ml / hr. Starting with the amount of IV fluid remaining at 2000, calculate the new infusion time and completion time of the IV. Infusion time Completion time 4. The doctor orders 500 ml of NS to infuse at 100 ml / hr. The nurse starts the IV at At 0700, the IV rate is decreased to 75 ml / hr. Starting with the amount of IV fluid remaining at 0700, calculate the new infusion time and completion time of the IV. Infusion time Completion time 5. At 1600, 1 L D5W is started to infuse over 8 hours. At 1900, the IV infiltrates. The nurse restarts the IV at 2100 at the same IV rate. Starting with the amount of IV fluid remaining at 2100, calculate the new infusion time and completion time of the IV. Infusion time Completion time 97 Copyright 2012, F. A. Davis Company

102 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Infusion and Completion Time Read each situation, and then make a clinical judgment. Provide a rationale for your decision or action. SITUATION: The nurse started 1 liter of D5/0.9% NS at 0700, to infuse at 125 ml / hr via gravity. The drop factor of the IV tubing is 15 gtt / ml. At 1200, the IV intake is 300 ml. In assessing the flow rate, the nurse counts 21 gtt / min. Which action(s) by the nurse are appropriate (select all that apply)? a. Increase the flow rate to 31 gtt / min. b. Increase the flow rate to 41 gtt / min for 4 hours. c. Report a completion time of d. Plan to give 1000 ml for the day shift. e. Administer the IV fluid through an infusion pump. Rationale / Discussion: 98 Copyright 2012, F. A. Davis Company

103 LABELING IV BAGS KEY POINTS: When labeling a flowmeter, be sure to include the start time and end time of the IV. Use military time to identify the hourly fluid intake on the flowmeter. Labeling IV Bags Label the following flowmeters to identify the IV fluid intake. 1. The doctor orders 1 L NS to infuse over 10 hours. The nurse starts the IV at Label the flowmeter with the hourly fluid intake. Start Time Copyright 2012, F. A. Davis Company

104 2. The nurse starts the IV at 0230, to infuse at 75 ml / hr. Label the flowmeter hourly. Start Time The nurse starts the IV at 0100, at 50 ml / hr. Label the flowmeter q.2h. Start Time 500 ml 0 5% Dextrose Injection Copyright 2012, F. A. Davis Company

105 4. The nurse starts the IV at 1300, to infuse at 150 ml / hr. Label the flowmeter hourly. Start Time 1000 ml 0 0.9% Normal Saline Shade in the amount of IV fluid in the bag at The nurse starts the IV at 2030 to infuse at 125 ml / hr. Label the flowmeter hourly. 500 ml Start Time 0 0.9% Normal Saline Shade in the amount of IV fluid in the bag at Copyright 2012, F. A. Davis Company

106 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Labeling IV Bags Read each situation, and then make a clinical judgment. Provide a rationale for your decision or action ml Start Time 0.9% Normal Saline SITUATION: The nurse started 1 liter of 0.9% NS at 0900, to infuse at 50 ml / hr. At 1200, the IV rate is increased to 125 ml / hr. The nurse relabels the flowmeter and reports an IV intake 1200 of 525 ml at This flowmeter: a. is labeled appropriately. b. reflects the increased rate. c. indicates when the IV will be finished. d. must be recalculated. Rationale / Discussion: 102 Copyright 2012, F. A. Davis Company

107 Module: PEDIATRIC CALCULATIONS ADMINISTERING MEDICATIONS TO CHILDREN KEY POINTS: The oral route is preferred for children. Children over 5 years can take chewable forms of medication. Special equipment is available for oral pediatric administration. Parenteral doses for children are generally not rounded, but are left at the tenths or the hundredths place. The maximum volume of a parenteral injection in children is generally 1 ml. For the subcut route, 0.5 ml is the maximum volume, and for the ID route, ml is the maximum volume of the injection. Shorter length (1/2-1 ) and smaller diameter (25G - 30G) needles are used. The smallest possible amount of diluent is added to dilute pediatric IV medications. A pedidrip tubing (60 gtt / ml) and a burette may be used to administer pediatric IV fluids and medications. Administering Medications to Children Solve the following problems using the method of your choice. 1. The physician prescribed divalproex sodium 0.25 gram daily p.o. Divalproex sodium is available from the pharmacy in 125 mg delayed-release tablets. How many tablets will the nurse give? 103 Copyright 2012, F. A. Davis Company

108 2. The child is to receive cefaclor 350 mg p.o. q.12h. The pharmacy sends strawberry-flavored cefaclor oral suspension in 125 mg / 5 ml strength. How many ml will the child receive per dose? 3. The doctor orders Diflucan 60 mg b.i.d. The nurse finds the following in the medication drawer. How many ml will the nurse give? 4. The order is for 75 mg of Dilantin p.o. t.i.d. for a 6-year-old child. The following medication is available. How many ml will the nurse give? 104 Copyright 2012, F. A. Davis Company

109 5a. Prochlorperazine 2.5 mg p.o. b.i.d. is ordered. The pharmacy sends prochlorperazine syrup 5 mg / 5 ml. How many ml will the patient receive? b. Fill in the most appropriate measuring device for this medication. 30 ml 25 ml 20 ml 15 ml 10 ml 5 ml 1/ / /2 6a. Methylprednisolone 20 mg IV q.12h. is ordered. The pharmacy sends the following medication. How many ml will the nurse administer per dose? b. Fill in the syringe m ml 105 Copyright 2012, F. A. Davis Company

110 7. The physician orders IV tobramycin 12 mg q.12h. The pharmacy sends the following vial of tobramycin. How many ml will the nurse give? 8a. The patient has a primary IV of D5/0.225% NS infusing by gravity flow at 75 ml / hr. The IV tubing is a pedidrip tubing. The physician orders ampicillin 250 mg in 50 ml D5W IV q.6h. The IVPB is to infuse over 1/2 hour. What is the flow rate of the IVPB? b. At what time will the IVPB be completed if the nurse starts the IVPB at 1400? 9. The patient is to receive ampicillin 100 mg. After mixing the ampicillin, the nurse adds it to the volume control chamber and fills up the chamber with D5W to the 50 ml mark. The IV medication is to infuse over 60 minutes. How many ml / hr will the nurse set on the IV pump? To IV bag Clamp 150 Volume control chamber Drip chamber Pedidrip IV to patient 106 Copyright 2012, F. A. Davis Company

111 DETERMINING SAFE DOSE KEY POINTS: In order to determine whether an ordered dose is safe for an individual child, the nurse needs the following information: the medication order, the child s weight (usually in kg) or body surface area (BSA), and the recommended dose from the drug reference. Recommended drug dosages can be stated as individual doses (for example, mg / kg or mcg / m 2 ), total daily doses, or dosage ranges. The nurse needs to read the drug reference information carefully to interpret the recommended drug dose correctly. The nurse calculates the recommended dose based on a child s weight or BSA, then compares it with the ordered dose. An ordered dose is considered safe when it is equal to or smaller than the dose recommended in the drug reference. Dosage Based on Body Weight Solve the following problems using the method of your choice. 1a. The physician orders cefdinir 200 mg p.o. q.12h., for a child who weighs 30 kg. The drug reference information states that the recommended dose for children from 6 months to 12 years is 7 mg / kg q.12h. What is the maximum safe dose based on the drug literature for this child? b. Is the ordered dose safe? 107 Copyright 2012, F. A. Davis Company

112 2a. The physician orders a digitalizing dose of IV digoxin 0.25 mg p.o. q.12h., for a 12-month-old child who weighs 8 kg. The drug reference information states that the recommended digitalizing dose for children from 1-24 months is mcg / kg. What is the maximum safe dose based on the drug literature for this child? b. Is the ordered dose safe? 3a. The physician orders furosemide oral solution 40 mg p.o. daily, for a child who weighs 66 lb. The drug reference information states that the recommended dose of p.o. furosemide for children over 1 month is 2 mg / kg as a single dose. Maximum dose = 6 mg / kg / day. What is the maximum safe dose based on the drug literature for this child? b. Is the ordered dose safe? 4a. A child who weighs 77 lb is started on oral morphine solution 20 mg p.o. q.3h. The recommended dose of oral morphine for children <50 kg is 0.3 mg / kg q.3-4h. initially. What is the maximum safe dose based on the drug literature for this child? _ b. Is the ordered dose safe? 108 Copyright 2012, F. A. Davis Company

113 5a. The order is for phenytoin sodium 125 mg IV q.8h., for a 15-year-old patient with frequent seizures. The patient weighs 55 kg. The drug reference information states that the recommended pediatric maintenance dose of phenytoin sodium is 6-7 mg / kg / 24 hr in 2-3 divided doses. What is the safe dose range based on the drug literature for this child? b. Is the ordered dose safe? Dosage Based on Body Surface Area Solve the following problems using the method of your choice. 1a. A child who has a BSA of 0.8 m 2 is given leucovorin calcium 5 mg q.6h. The drug reference book states that the recommended dose for children is 7 mg / m 2 q.6h. What is the maximum safe dose based on the drug literature for this child? b. Is the ordered dose safe? 2a. An order is written for zidovudine 0.25 g p.o. q.6h., for a child who has a BSA of 1.1 m 2. The drug reference book states that the recommended dose for children from 3 months to 12 years is mg / m 2 q.6h. What is the maximum safe dose based on the drug literature for this child? b. Is the ordered dose safe? 109 Copyright 2012, F. A. Davis Company

114 3a. The physician prescribes vinblastine 10 mg IV q.week, for a child who weighs 75 lb and has a body surface area of 1.15 m 2. The drug reference book states that the recommended dose of vinblastine for children is 2.5 mg / m 2 as a single dose initially, up to 7.5 mg / m 2 / q.1-2 weeks up to 12 weeks. What is the maximum safe dose based on the drug literature for this child? b. Is the ordered dose safe? 4a. The order is for 0.2 mg q.am of a drug for a child with a BSA of 0.4 m 2. The recommended dose of the drug is 0.55 mg / m 2 daily. What is the maximum safe dose based on the drug literature for this child? b. Is the ordered dose safe? 5a. An 11-year-old child with leukemia and an acute varicella zoster infection is started on acyclovir 500 mg IV q.8h. The child s BSA is 1.18 m 2. The recommended dose of acyclovir for immunosuppressed children <12 years old with varicella zoster is 500 mg / m 2 q.8h. for 7 days. What is the maximum safe dose based on the drug literature for this child? b. Is the ordered dose safe? 110 Copyright 2012, F. A. Davis Company

115 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Determining Safe Dose Read each situation, and then make a clinical judgment. Provide a rationale for your decision or action. Date 2/15 Physician's Orders Lamotrigine 10 mg p.o. b.i.d. Patient M ID ******* SITUATION: The physician is starting lamotrigine drug therapy on an 8-year-old child who weighs 27 kg. The drug reference information states that the recommended initial pediatric dose of lamotrigine is 0.6 mg / kg / day in 2 divided doses for the first 2 weeks. Which action by the nurse is most appropriate? a. Administer the medication as ordered. c. Ask the pharmacist if the ordered dose is correct. b. Question the ordered dose. d. Ask the parent what dose the child has been taking. Rationale / Discussion: 111 Copyright 2012, F. A. Davis Company

116 NASOGASTRIC FLUID REPLACEMENT KEY POINTS: To calculate fluid replacement for a child with a large volume of NG drainage, the nurse needs the following information: the rate of the primary IV, the maximum hourly IV rate, the amount of NG drainage, and the time interval for measuring and replacing the output. NG fluid replacement problems usually involve solving for the infusion and completion time of the replacement IV fluid. Working With Nasogastric Fluid Replacement Problems Solve the following problems using the method of your choice. 1a. An adolescent patient with an NG tube set to low continuous suction has an order for 1 L D5/ ml / hr. The NG drainage is to be measured q.8h. and replaced with a second IV of D5W with 10 meq KCl per 500 ml. The patient is to receive no more than 150 ml / hr IV. What is the rate of the primary IV? b. What is the maximum hourly IV rate? c. The patient s NG tube drains 380 ml. What is the infusion time of the replacement IV? d. What is the completion time of the replacement IV if replacement is started at 1500? 112 Copyright 2012, F. A. Davis Company

117 2a. The order is for 500 ml D5/0.225% 63 ml / hr. The NG drainage is to be measured and replaced with the primary IV solution q.4h. Maximum hourly IV rate is not to exceed 85 ml / hr. What is the rate of the primary IV? b. The nurse can increase the IV by how many additional ml / hr during the replacement of the NG drainage? c. The child s NG tube drains 66 ml. What is the infusion time of the replacement IV fluid? d. The fluid replacement is started at 12 noon. What is the completion time? 3a. The physician writes the following orders: 1. IV 500 ml 0.33% 75 ml / hr. 2. Replace NG drainage ml for ml q.4h. with 2nd IV of 0.45% NS with 10 meq KCl per 500 ml. 3. Maximum hourly IV rate 100 ml / hr. The NG output at 0400 is 100 ml. What is the infusion time of the replacement IV? b. What is the completion time if the replacement IV is started at 0430? 113 Copyright 2012, F. A. Davis Company

118 4a. The physician writes the following orders: 1. IV 500 ml D5/0.225% NS q.10h. 2. Replace NG drainage ml for ml with the maintenance IV fluid q.4h. 3. Maximum hourly IV rate 80 ml / hr. The NG output at 2200 is 135 ml. What is the infusion time of the replacement IV fluid? b. What is the completion time if the replacement IV is started at 2245? 5a. The physician writes the following orders: 1. IV 250 ml D5/ 0.9% NS at 25 ml / hr. 2. Replace NG drainage ml for ml q.4h. 3. Maximum hourly IV rate 50 ml / hr. The NG output at 1500 is 65 ml. What is the infusion time of the replacement IV fluid? b. What is the completion time if the replacement IV is started at 1600? 6a. The physician writes the following orders: 1. IV 250 ml D5W at 40 ml / hr. 2. Replace NG drainage ml for ml with the maintenance IV fluid q.8h. 3. Maximum hourly IV rate 75 ml / hr. The NG output at 0600 is 115 ml. What is the infusion time of the replacement IV fluid? b. What is the completion time if the replacement IV is started at 0700? 114 Copyright 2012, F. A. Davis Company

119 Module: TITRATION OF IV MEDICATIONS TITRATION OF IV MEDICATIONS KEY POINTS: With titration problems, the nurse usually needs to calculate the number of ml / hr to set on the IV pump. Occasionally, the nurse must calculate the amount of medication infusing per hour. Information needed to solve titration problems includes the total drug, the total volume of IV fluid, and the amount of drug ordered to infuse hourly. Titration orders can be written as a dosage range or as a single dose of medication. Titration in Common Clinical Practice Solve the following titration problems. 1. Heparin 25,000 units in 250 ml D5W is sent up from the pharmacy. The order is to administer heparin at 1000 units / hr. How many ml / hr will the nurse set on the IV pump? 2. The pharmacy sends an IV of 125 mg diltiazem HCl in 500 ml D5W. The physician has ordered diltiazem HCl 5 mg / hr. Calculate the ml / hr. 3. One gram of aminophylline is added to 500 ml NS. The order is to infuse the IV over 10 hours. Calculate the mg / hr that the patient will receive. 4. The doctor writes an order for heparin 1400 units / hr. The pharmacy sends an IV of 500 ml D5W with 20,000 units of heparin. What rate will the nurse set on the IV pump? 115 Copyright 2012, F. A. Davis Company

120 5. The physician orders IV morphine sulfate 2-5 mg / hr for pain management. The pharmacy sends an IV of 250 mg of morphine sulfate in 500 ml D5W. What rate will the nurse set on the IV pump to administer 3 mg / hr? 6a. A patient with severe asthma who weighs 55 kg is started on an IV theophylline drip in the emergency room. An IV of 250 mg theophylline ethylenediamine in 500 ml NS is started at The order is to start the IV infusion at 0.5 mg / kg / hr. The dose to be increased as needed by 0.1 mg / kg / hr q.30 min, up to a maximum of 0.7 mg / kg / hr. Calculate the ml / hr that the nurse will set on the infusion pump at b. If the theophylline drip is increased as ordered at 1330, what rate will be set on the IV pump? Complex Titration Problems in Critical Care Solve the following titration problems. 1. Ordered: IV dobutamine 100 mcg / min Available: dobutamine 250 mg in 250 ml D5W At the hand off report, the nurse is informed that the patient is receiving 5 ml / hr via IV pump. a. Calculate the ordered mg / hr. b. Calculate the ml / hr based on the order. c. Is the set rate correct? 116 Copyright 2012, F. A. Davis Company

121 2. Ordered: 1 mg lidocaine / min IV infusion Available: 2 g lidocaine in 500 ml D5W a. Calculate the mg / hr. b. Calculate the ml / hr. c. If the lidocaine is increased to 2 mg / min, calculate the ml / hr. 3. Ordered: IV infusion lidocaine 4 mg / min Available: 1 g lidocaine in 500 ml D5W a. Calculate the ml / hr. b. If the rate is reduced to 2 mg / min, calculate the ml / hr. 4. The pharmacy sends an IV of magnesium sulfate 22 gram in 500 ml D5W. The order is for 50 mg / min. Calculate the ml / hr. 5. A patient with ventricular ectopic beats has a stat order for an IV infusion of lidocaine at a rate of 30 ml / hr. The IV contains 1 g lidocaine in 500 ml D5W. Calculate the mg / hr that the patient will receive. 6. Pronestyl 1 gram in 250 ml NS is ordered for a patient with frequent PVCs, to infuse at 1 ml / min. Calculate the mg / min that the patient is receiving. 117 Copyright 2012, F. A. Davis Company

122 7. The order is for IV dopamine HCl 400 mg in 500 ml NS. The patient is to receive 750 mcg / min. What rate will the nurse set on the IV pump? 8. Ordered: Nitroglycerine 10 mcg / min IV infusion Available: Nitroglycerine 50 mg in 250 ml NS What rate will the nurse set on the IV pump? 9. The order is for IV dopamine HCl 400 mg / 500 ml NS. The patient is to receive mcg / min. What rate will the nurse set on the IV pump to administer the lowest dosage of dopamine HCl? 10. The order is for NTG mcg / min via IV infusion to relieve chest pain. NTG 50 mg in 250 ml NS is available. What rate will the nurse set on the IV pump to deliver the highest dosage? 11. The physician orders dopamine 20 mcg / kg / min for a patient who weighs 80 kg. The pharmacy sends an IV of 400 mg of dopamine in 500 ml D5W. What rate will the nurse set on the IV pump? 12. The physician orders milrinone lactate mcg / kg / min IV for a patient with CHF who weighs 121 lb. The pharmacy sends an IV of 20 mg of milrinone lactate in 150 ml D5W. What rate will the nurse set on the IV pump to administer the lowest dosage? 118 Copyright 2012, F. A. Davis Company

123 13. The physician orders propranolol 1 mg / hr. The pharmacy sends an IV of 15 mg propranolol in 500 ml NS. Calculate the ml / hr. 14a. The patient has a dopamine drip running at 45 ml / hr. The order is for 400 mg dopamine HCl in 500 ml D5W to infuse at 5-15 mcg / kg / min. The dopamine is started at 8 mcg / kg / min. The patient weighs 165 pounds. Is the correct rate set on the IV pump? b. If the rate is increased to 9 mcg / kg / min, what rate should be set on the IV pump? 119 Copyright 2012, F. A. Davis Company

124 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Titration Medication Read each situation, and then make a clinical judgment. Provide a rationale for your decision or action. Date 7/10 Physician s Orders Start D5W 500 ml with 20,000 units heparin. Heparin to infuse at 1100 units every hour. Patient C ID ******* SITUATION: To carry out this order safely, the nurse would (select all that apply): a. set the infusion rate at ml / hr. b. set the infusion rate at gtt / min. c. use a minidrop IV tubing for gravity flow infusion. d. set up the IV using an infusion pump. e. discontinue the IV once the 500 ml have infused. Rationale / Discussion: 120 Copyright 2012, F. A. Davis Company

125 ANSWERS Module: BASIC MATH REVIEW Working With Addition of Fractions (pp. 1-2) 1. 3/ / / / / / / / / /4 Working With Subtraction of Fractions (p. 2) 1. 1/ /2 2. 3/ / / / / / / /10 Working With Multiplication of Fractions (p. 3) 1. 3/ / / / / / / / / /54 Working With Division of Fractions (pp. 3-4) / / / / / / / / / Copyright 2012, F. A. Davis Company

126 Working With Addition of Decimals (pp. 4-5) Working With Subtraction of Decimals (p. 5) Working With Multiplication of Decimals (p. 6) Working With Division of Decimals (pp. 6-7) Copyright 2012, F. A. Davis Company

127 Module: METHODS OF CALCULATION Working With a Method of Calculation (pp. 8-13) 1. 2 tablets ml /2 tablets ml 3. 2 pills ml tablet ml 5. 3 caplets days ml ml 7. 6 ml 19a. 0.4 ml ml b. 5 doses 9. 3 ml 20a. 0.8 ml ml b. 5 doses days c ml days d. 6 doses Module: SYSTEMS OF MEASUREMENT Working With the Metric System (pp ) ml mg ml g 3. 1 g mg mg mg 5. 10,000 mcg mcg mcg g g mm L ml dm ml ,000 M ml mm ml g tablets L ml 123 Copyright 2012, F. A. Davis Company

128 Working With the Household System (pp ) 1. 6 tsp ml 2. 2 T 3. 3 tsp oz 5. 8 oz lb 7. 1 T 2 TBS 1 TBS 1 TSP 1/2 TSP oz oz 30 ml 25 ml 20 ml 15 ml 10 ml 5 ml Working With Conversions Between Systems (pp ) ml ml mg cm 3. 1 oz mm mcg lb mg kg mg L oz tablets 8. 5 tsp ml g lb ml tablets t tsp t ml ml Module: INTAKE AND OUTPUT Working With Intake and Output (pp ) 1. I 960 ml 7. I 1224 ml O 440 ml O 425 ml 2. I 270 ml 8. I 1330 ml O 280 ml O 605 ml 124 Copyright 2012, F. A. Davis Company

129 3. O 1410 ml 9. I 970 ml O 480 ml 4. I 300 ml 10. I 675 ml O 270 ml 5. I 2020 ml 11. I 1660 ml O 595 ml O 800 ml 6. I 1000 ml 12. I 750 ml O 1125 ml 13. I 375 ml Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Intake and Output (p. 26) c. question the administration of the IVPBs. CORRECT: The documented parenteral intake identifies the primary IV intake (600 ml) for the day shift and an IVPB intake of 100 ml. Each IVPB contained 100 ml. The day nurse reported that two IVPBs were given. INCORRECT: a. question the recorded 100 ml urine output. The situation does not indicate any reason to question the 100 ml output. b. recalculate the primary IV intake. The primary IV has infused appropriately for the shift. d. plan to administer an IVPB of KCl. The nurse should clarify if the IVPB was given before planning the administration of another dose. 125 Copyright 2012, F. A. Davis Company

130 Working With Nasogastric Tube Feeding Problems (pp ) ml ml ml ml ml ml ml ml ml ml Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Nasogastric Tube Feeding (p. 30) b. The amount of water added to the formula. CORRECT: The ordered formula strength is 2/3. The nurse starts with 200 ml of formula. To make a 2/3- strength formula, the nurse needs to add 100 ml of water, not 80 ml. INCORRECT: a. The documented NG tube intake should be 400 ml. The documented NG tube intake is correct. c. The IV intake is incorrect for the ordered rate. The documented IV intake is correct. d. The formula strength should be questioned. The formula strength is ordered by the physician. Module: READING MEDICATION LABELS Working With Reading Medication Labels (pp ) 1. a. Coreg 126 Copyright 2012, F. A. Davis Company

131 b. carvedilol c. 25 mg / tablet d. tablet e. oral 2. a. lorazepam b. 4 mg / ml c. liquid for injection (milliliters) d. IV or IM e. Yes f. single-dose g. 0.7 ml 3. a. Diflucan b. fluconazole c. Add 24 ml of distilled water or purified water. Shake well. 4. a. morphine sulfate b. 15 mg / ml c. 20 ml d. SC, IM, IV, epidural or intrathecal e. Yes f. No g. 0.8 ml 5. a. 7.5 ml 6. a. haloperidol b. 50 mg / 10 ml 5 mg / ml c. IM d. No e. No f. 0.5 ml 7. a. Corvert b. 1 mg / 10 ml 0.1 mg / ml c. IV use only d. store at controlled room temperature 127 Copyright 2012, F. A. Davis Company

132 8. a mg / ml b. IV c. No d. 0.5 ml 9. a. 150 mg / 3 ml 10. a. Humulin R b. 500 units 11. a. Novolog b. 6 units 12. a. Novolin 70/30 b. 22 units 13. a. Humalog 50/50 b. 17 units 14. Trade name X Generic name X Dosage strength X Form of the drug Route of administration X Controlled substance X Storage information X Total amount 15. Trade name X Generic name X Dosage strength X Form of the drug X Route of administration Controlled substance Storage information X Total amount 128 Copyright 2012, F. A. Davis Company

133 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Reading Medication Labels (p. 40) d. not administer this drug. CORRECT: The order is for morphine, not hydromorphone. Although both drugs are opioid analgesics, they are different drugs. The nurse needs to ensure that the available drug corresponds to what is ordered. INCORRECT: a. give 1.5 ml of the drug using two vials. Before calculating how much medication to give, the nurse should ensure that correct drug is being prepared. The order is for morphine, not hydromorphone. b. call the pharmacist to double check the order. The nurse should first check the original order found in the Physician s Order sheet. c. research the appropriate route of administration. Although this is important, the nurse should first ensure that the available drug corresponds to what is ordered. Module: ORAL MEDICATIONS Working With Oral Medications (pp ) 1. 2 tablets days 2. 1/2 tablet 14. 1/2 tablet 3. 2 tablets tablet 4. 2 tablets ml 5. 2 tablets ml mg tab (6.25mg) 7. 8 ml mg 8. 2 tsp tablespoon ml tablets tablet ml ml tsp tablets 129 Copyright 2012, F. A. Davis Company

134 24. Digoxin 0.5 tablet Captopril 1 tablet furosemide 2 tabs capsules ml caplets tablets 29. a. 59 ml b. 2 tsp 30. a. 26 ml b. 2 tsp Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Oral Medications (p. 50) b. Call the pharmacist regarding the propranolol. CORRECT: The nurse should call the pharmacist to clarify the propranolol 60 mg ER found in the patient s medication drawer. d. Give the hydralazine and the K-Dur at CORRECT: The nurse can administer the 0900 hydralazine and the K-Dur to the patient. The nurse should not administer the propranolol until it is clarified. INCORRECT: a. Give all the 0900 medications. The nurse should question the propranolol 60 mg ER prior to administering the drug. c. Call the pharmacist regarding the K-Dur. The K-Dur may be given as ordered. e. Give the hydralazine and propranolol at The nurse should hold and question the administration of the propranolol 60 mg ER. 130 Copyright 2012, F. A. Davis Company

135 Module: SYRINGES AND NEEDLES Working With Syringes (pp ) ml ml ml minims minims ml ml 1/2 1/ /2 1/ / / m ml m ml m ml m ml 1 1/ /2 2 1/2 131 Copyright 2012, F. A. Davis Company

136 ml m ml ml ml units UNITS 1/ / /2 USE U-100 INSULIN units USE U-100 INSULIN UNITS units USE U-100 INSULIN UNITS units USE U-100 INSULIN UNITS ml 132 Copyright 2012, F. A. Davis Company

137 units USE U-100 INSULIN units USE U-100 INSULIN UNITS units USE U-100 INSULIN ml ml 1/ / / ml UNITS UNITS ml m ml 133 Copyright 2012, F. A. Davis Company

138 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Syringes (p. 55) d. should divide the medication into two injections, using two 3 ml syringes. CORRECT: For intramuscular (IM) injections, it is recommended that no more than 3 ml be administered into one site. Although the patient would receive two injections, this is the safest action. INCORRECT: a. has correctly determined the most appropriate syringe to measure and administer this dose accurately. For IM injections, it is recommended that no more than 3 ml be administered into one site. b. needs to contact the physician and request a higher dosage strength of the medication. It is not necessary to contact the physician since the ordered dose can be administered through two separate IM injections. c. needs to contact the pharmacist to ensure that the ordered dose has been correctly calculated. The nurse can ask another professional nurse to check the calculation. Working With Needles (p. 56) 1. 28G 1/2 or 31G 5/ G 1 1/ G 3/ G G 5/ G Copyright 2012, F. A. Davis Company

139 Working With Needles (pp ) 1. Meperidine 75 mg (1 ml) IM b. 22G 1 1/2 1/ / /2 2. Filgrastim 300 mcg (1 ml) subcut b. 25G 5/8 1/ / /2 3. Heparin 5000 units (0.67 ml) subcut a m 25G 5/ ml 4. Hepatitis A vaccine 1 ml IM b. 23G 1 1/2 1/ / /2 5. Ketorolac 60 mg (2 ml) IM b. 22G 1 1/2 1/ / /2 135 Copyright 2012, F. A. Davis Company

140 6. Humulin Regular insulin 17 units subcut a. 28G 1/ USE U-100 INSULIN UNITS 7. Humulin Regular insulin 6 units and Humulin NPH insulin 13 units subcut a. 28G 1/2 5 USE U-100 INSULIN UNITS 8. Heparin 1000 units (0.1 ml) subcut a m 25G 5/ ml 9. Morphine sulfate 1 mg (16 minims) subcut b m 25G 1/ ml 136 Copyright 2012, F. A. Davis Company

141 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Needles (p. 60) d. 25G 1/2 CORRECT: Medications ordered via the subcut route are meant to be injected into the adipose tissue. A 25G 1/2 needle will appropriately administer the ordered medication into the correct site. INCORRECT: a. 18G 1 b. c. 20G 1 1/2 22G 1 These needles cannot be used for subcut injections into the abdomen. Module: PARENTERAL MEDICATIONS Working With Parenteral Medications (pp ) ml ml ml 4. 2 ml Fill in the syringe. 1/ / /2 137 Copyright 2012, F. A. Davis Company

142 5. morphine sulfate = 0.6 ml glycopyrrolate = 0.4 ml Total amount = 1 ml Fill in the syringe with the total amount ml Fill in the syringe m ml ml minims m ml ml Fill in the ordered dose in each syringe m ml 1/ / /2 1/ / /2 1/ / /2 138 Copyright 2012, F. A. Davis Company

143 ml Fill in the syringe m ml ml units Fill in the syringe. USE U-100 INSULIN units Fill in the syringe units Fill in the syringe. USE U-100 INSULIN UNITS units Fill in the syringe. USE U-100 INSULIN units Fill in the syringe UNITS UNITS UNITS USE U-100 INSULIN UNITS USE U-100 INSULIN 139 Copyright 2012, F. A. Davis Company

144 units Fill in the syringe. USE U-100 INSULIN UNITS ml ml ml ml ml ml ml ml minims ml m ml ml ml ml 140 Copyright 2012, F. A. Davis Company

145 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Parenteral Medications (p. 71) d ml CORRECT: The dosage strength of levothyroxine is 40 mcg / ml. The ordered dose is mg, which is equivalent to 65 mcg. INCORRECT: a ml Use the dosage strength of 40 mcg / ml as listed under the Usual Dosage information. b ml Use the dosage strength of 40 mcg / ml as listed under the Usual Dosage information. c. 1.5 ml Use the dosage strength of 40 mcg / ml as listed under the Usual Dosage information. Module: RECONSTITUTION OF POWDERED MEDICATIONS Working With Single-Strength Reconstitution (pp ) 1.a. 2.5 ml b. sterile water for injection c. 330 mg / ml d ml 2.a. 4.6 ml b. bacteriostatic water for injection c. 200,000 units / ml d. 1.5 ml 3. date and time of reconstitution; nurse s initials 141 Copyright 2012, F. A. Davis Company

146 4.a. 2 ml b. sterile water for injection c. 125 mg / ml d. 1.6 ml 5.a. 1 g / 2.6 ml b. 1.3 ml 6.a. 2 ml b. sterile water for injection c. 225 mg / 1 ml d. 2 ml 7.a. 9.8 ml b. 5,000 units per ml c. 1.2 ml d. date and time of reconstitution; nurse s initials ml Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Single- Strength Reconstitution (p. 78) c. Question the date of reconstitution. CORRECT: Although the nurse s initials and time of reconstitution are written, the date of reconstitution is not written on the Augmentin label. The nurse needs to clarify this prior to administering the drug to the patient. INCORRECT: a. Convert the tsp to ml. The nurse may want to do this prior to administration, however, it is more important to first clarify the date of reconstitution. b. Administer the measured dose. The nurse must first clarify the date of reconstitution. d. Use a 3 ml syringe to measure the dose. It is more important to first clarify the date of reconstitution. 142 Copyright 2012, F. A. Davis Company

147 Working With Multiple-Strength Reconstitution (pp ) 1. the smallest volume of diluent 2.a. 100 mg / ml b. 7.5 ml c. date and time of reconstitution; nurse s initials; circle selected volume of diluent and corresponding dosage strength 3.a. 100,000 units / ml b. 500,000 units / ml c. 9.6 ml of diluent give 10 ml 4.6 ml of diluent give 5 ml 1.6 ml of diluent give 2 ml 4.a. 75 ml of diluent 250,000 units / ml 33 ml of diluent 500,000 units / ml 11.5 ml of diluent 1,000,000 units / ml b. 75 ml of diluent give 3 ml 33 ml of diluent give 1.5 ml 11.5 ml of diluent give 0.75 ml c. 7 days d. date and time of reconstitution; nurse s initials; circle selected volume of diluent and corresponding dosage strength 5.a. 3.5 ml of diluent 500 mg / ml 7.2 ml of diluent 250 mg / ml b. 3.5 ml of diluent give 1.4 ml 7.2 ml of diluent give 2.8 ml c. 1 hour at room temperature; 6 hours under refrigeration d. 3.5 ml is preferable so that the volume of the IM injection is smaller. e. date and time of reconstitution; nurse s initials; circle selected volume of diluent and the corresponding dosage strength 143 Copyright 2012, F. A. Davis Company

148 6.a. After reading the label, the nurse can identify the (check all that apply): X routes of administration X storage information b. To administer the ordered dose (500 mg), the nurse: X should read the accompanying literature. Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Multiple-Strength Reconstitution (p. 84) b. Recalculate the dose drawn up. CORRECT: The circle around the dosage strength indicates that the drug has already been reconstituted. The reconstituted drug yields 500,000 units / ml. The order is for 2,400,000 units. After calculating, the nurse will draw up 4.8 ml. INCORRECT: a. Add the 5 ml to the IV bag. The order is for 2,400,000 units. After calculating, the answer is 4.8 ml. The nurse can accurately measure this dose using a 5 ml syringe. c. Add 9.6 ml of penicillin G potassium to the IV bag. The nurse needs to use the reconstituted dosage strength that is circled on the label. d. Use 1,000,000 U / ml to calculate the desired dose. The nurse needs to use the reconstituted dosage strength that is circled on the label. Module: IV CALCULATIONS Working With Milliliters per Hour (pp ) ml / hr ml / hr ml / hr 144 Copyright 2012, F. A. Davis Company

149 ml / hr ml / hr ml / hr ml / hr ml / hr ml / hr ml / hr Working With Flow Rate (p ) gtt / min gtt / min gtt / min 4. 8 gtt / min gtt / min gtt / min gtt / min gtt /min gtt / min gtt / min Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Milliliters per Hour and Flow Rate (p. 89) a. continue to monitor the IV intake at 13 gtt / min. CORRECT: The IV is set at the appropriate rate to deliver 50 ml / hr. INCORRECT: b. question the oral intake for the day shift. There is no indication for questioning the oral intake in this situation. c. increase the flow rate to 31 gtt / min. The IV rate is accurate and should not be increased without an MD order. d. change the IV tubing to a minidrop. The IV tubing does not need to be changed. The flow rate can be accurately set and monitored with the current tubing. 145 Copyright 2012, F. A. Davis Company

150 Working With Direct IV Medication Administration (pp ) 1. 5 minutes minutes 3. 4 minutes 4. 5 minutes 5. 2 minutes 6. 1 minute 7. 2 minutes Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Direct IV Medication Administration (p. 93) b. administer 0.8 ml over 1 minute. CORRECT: The recommended rate for direct IV administration is 1 minute. INCORRECT: a. give the ordered dose slowly into the vein. For safe administration, the nurse needs to follow the recommended rate and routes of administration. c. add the atropine dose to the primary IV fluid. The order is for IVP (direct IV administration). The atropine should not be added to the primary IV fluid. d. dilute with 10 ml normal saline. The drug reference information indicates that this drug should be administered undiluted. Working With Infusion Time (pp ) 1. 8 hours 2. 8 hours 20 minutes hours 20 minutes 4. 6 hours 24 minutes minutes 6. 3 hours 20 minutes 146 Copyright 2012, F. A. Davis Company

151 Working With Completion Time (pp ) 1. 4:00 PM or :10 PM or :00 AM or :30 AM or :45 PM or :00 PM or 1400 Working With Infusion and Completion Time (pp ) 1. Infusion time = 9 hours Completion time = 8:00 PM or Infusion time = 3 hours 30 minutes Completion time = 7:00 PM or Infusion time = 5 hours Completion time = 1:00 AM or Infusion time = 4 hours 40 minutes Completion time = 11:40 AM or Infusion time = 5 hours Completion time = 2:00 AM or 0200 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Infusion and Completion Time (p. 98) a. Increase the flow rate to 31 gtt / min. CORRECT: The nurse should increase the flow rate to administer 125 ml / hr. c. Report a completion time of CORRECT: At 1200, there are 700 ml of fluid left in the primary IV. Following the physician s orders to administer 125 ml / hr, it will take 5 hours and 36 minutes for 700 ml at 1200 to infuse into the patient. INCORRECT: b. Increase the flow rate to 41 gtt / min for 4 hours. The flow rate should not be adjusted to catch up. d. Plan to give 1000 ml for the day shift. The nurse must document the actual amount of IV fluid given for the shift. Because the IV is behind, the patient will not receive 1000 ml for the shift. e. Administer the IV fluid through an infusion pump. The IV has been ordered to infuse via gravity. The nurse should assess the IV site to ensure proper placement. 147 Copyright 2012, F. A. Davis Company

152 Labeling IV Bags (pp ) 1. Start 2. Time Start Time Start Time ml 0 0 5% Dextrose Injection Copyright 2012, F. A. Davis Company

153 4. Start Time ml % Normal 100 Saline Start Time ml % Normal Saline Copyright 2012, F. A. Davis Company

154 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Labeling IV Bags (p. 102) d. must be recalculated. CORRECT: The nurse has made an error in the markings of the hourly fluid intake, beginning with the hourly fluid level at 1400, which should be at the 400 ml fluid level. INCORRECT: a. is labeled appropriately. There is an error with the hourly fluid level marking beginning at b. reflects the increased rate. The hourly fluid level intake is marked incorrectly on the flowmeter beginning at c. indicates when the IV will be finished. Since the hourly fluid level is not correct, the completion time is also incorrect. Module: PEDIATRIC CALCULATIONS Administering Medications to Children (pp ) 1. 2 tablets ml 3. 6 ml 4. 3 ml 5a. 2.5 ml b. 1/ / /2 6a ml b m ml 150 Copyright 2012, F. A. Davis Company

155 ml 8a. 100 gtt / min b ml / hr Dosage Based on Body Weight (pp ) 1a. 210 mg q.12h. b. Yes, the dose is safe. 2a. 400 mcg / dose b. Yes, the dose is safe. 3a. 180 mg / day b. Yes, the dose is safe. 4a mg q.3-4h. b. No, the dose is not safe. 5a mg / dose b. Yes, the dose is safe. Dosage Based on Body Surface Area (pp ) 1a. 5.6 mg q.6h b. Yes, the dose is safe. 2a. 198 mg / dose b. No, the dose is not safe. 3a mg /q.1-2 weeks up to 12 weeks b. No, the dose is not safe. 4a mg / day b. Yes, the dose is safe. 5a. 590 mg q.8h. for 7 days b. Yes, the dose is safe. 151 Copyright 2012, F. A. Davis Company

156 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Determining Safe Dose (p. 111) b. Question the ordered dose. CORRECT: The recommended total daily initial dose for a child weighing 27 kg is 16.2 mg / day. The order is for 10 mg b.i.d. The child will receive 20 mg /day. INCORRECT: a. Administer the medication as ordered. The nurse should first question the ordered dose, since it is more than the recommended initial dose. c. Ask the pharmacist if the ordered dose is correct. The nurse should communicate directly with the physician and clarify the ordered dose. d. Ask the parent what dose the child has been taking. The situation indicates that the physician is starting lamotrigine drug therapy on the child. Working With Nasogastric Fluid Replacement Problems (pp ) 1a. 100 ml / hr b. 150 ml / hr c. 7 hours 36 minutes d or 10:36 PM 2a. 63 ml / hr b. 22 ml / hr c. 3 hours d or 3:00 PM 3a. 4 hours b or 8:30 AM 4a. 4 hours 30 minutes b or 3:15 AM 5a. 2 hours 36 minutes b or 6:36 PM 6a. 3 hours 17 minutes b or 10:17 AM 152 Copyright 2012, F. A. Davis Company

157 Module: TITRATION OF IV MEDICATIONS Titration in Common Clinical Practice (pp ) ml / hr ml / hr mg / hr ml / hr 5. 6 ml / hr 6a. 55 ml / hr b. 66 ml / hr Complex Titration Problems in Critical Care (pp ) 1. a. 6 mg / hr b. 6 ml / hr 8. 3 ml / hr c. No ml / hr 2. a. 60 mg / hr ml / hr b. 15 ml / hr ml / hr c. 30 ml / hr ml / hr 3. a. 120 ml / hr ml / hr b. 60 ml / hr 14. a. Yes ml / hr b. 51 ml / hr mg / hr 6. 4 mg / min ml / hr 153 Copyright 2012, F. A. Davis Company

158 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Titration Medication (p. 120) a. set the infusion rate at 28 ml / hr. CORRECT: After calculating, the nurse will infuse the heparin at 28 ml / hr. d. set up the IV using an infusion pump. CORRECT: The nurse will infuse the heparin at 28 ml / hr using an infusion pump. INCORRECT: b. set the infusion rate at gtt / min. Heparin is a high alert drug. It is safer to administer this drug through an infusion pump (ml / hr). c. use a minidrop IV tubing for gravity flow infusion. Heparin is a high alert drug. Therefore, every effort must be made to ensure accuracy in the administration of the ordered dose. An infusion pump accurately delivers the set rate. e. discontinue the IV once the 500 ml have infused. This is a continuous infusion and should not be discontinued without the physician s order. 154 Copyright 2012, F. A. Davis Company

159 ANSWERS Module: BASIC MATH REVIEW Working With Addition of Fractions (pp. 1-2) 1. 3/ / / / / / / / / /4 Working With Subtraction of Fractions (p. 2) 1. 1/ /2 2. 3/ / / / / / / /10 Working With Multiplication of Fractions (p. 3) 1. 3/ / / / / / / / / /54 Working With Division of Fractions (pp. 3-4) / / / / / / / / / Copyright 2012, F. A. Davis Company

160 Working With Addition of Decimals (pp. 4-5) Working With Subtraction of Decimals (p. 5) Working With Multiplication of Decimals (p. 6) Working With Division of Decimals (pp. 6-7) Copyright 2012, F. A. Davis Company

161 Module: METHODS OF CALCULATION Working With a Method of Calculation (pp. 8-13) 1. 2 tablets ml /2 tablets ml 3. 2 pills ml tablet ml 5. 3 caplets days ml ml 7. 6 ml 19a. 0.4 ml ml b. 5 doses 9. 3 ml 20a. 0.8 ml ml b. 5 doses days c ml days d. 6 doses Module: SYSTEMS OF MEASUREMENT Working With the Metric System (pp ) ml mg ml g 3. 1 g mg mg mg 5. 10,000 mcg mcg mcg g g mm L ml dm ml ,000 M ml mm ml g tablets L ml 123 Copyright 2012, F. A. Davis Company

162 Working With the Household System (pp ) 1. 6 tsp ml 2. 2 T 3. 3 tsp oz 5. 8 oz lb 7. 1 T 2 TBS 1 TBS 1 TSP 1/2 TSP oz oz 30 ml 25 ml 20 ml 15 ml 10 ml 5 ml Working With Conversions Between Systems (pp ) ml ml mg cm 3. 1 oz mm mcg lb mg kg mg L oz tablets 8. 5 tsp ml g lb ml tablets t tsp t ml ml Module: INTAKE AND OUTPUT Working With Intake and Output (pp ) 1. I 960 ml 7. I 1224 ml O 440 ml O 425 ml 2. I 270 ml 8. I 1330 ml O 280 ml O 605 ml 124 Copyright 2012, F. A. Davis Company

163 3. O 1410 ml 9. I 970 ml O 480 ml 4. I 300 ml 10. I 675 ml O 270 ml 5. I 2020 ml 11. I 1660 ml O 595 ml O 800 ml 6. I 1000 ml 12. I 750 ml O 1125 ml 13. I 375 ml Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Intake and Output (p. 26) c. question the administration of the IVPBs. CORRECT: The documented parenteral intake identifies the primary IV intake (600 ml) for the day shift and an IVPB intake of 100 ml. Each IVPB contained 100 ml. The day nurse reported that two IVPBs were given. INCORRECT: a. question the recorded 100 ml urine output. The situation does not indicate any reason to question the 100 ml output. b. recalculate the primary IV intake. The primary IV has infused appropriately for the shift. d. plan to administer an IVPB of KCl. The nurse should clarify if the IVPB was given before planning the administration of another dose. 125 Copyright 2012, F. A. Davis Company

164 Working With Nasogastric Tube Feeding Problems (pp ) ml ml ml ml ml ml ml ml ml ml Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Nasogastric Tube Feeding (p. 30) b. The amount of water added to the formula. CORRECT: The ordered formula strength is 2/3. The nurse starts with 200 ml of formula. To make a 2/3- strength formula, the nurse needs to add 100 ml of water, not 80 ml. INCORRECT: a. The documented NG tube intake should be 400 ml. The documented NG tube intake is correct. c. The IV intake is incorrect for the ordered rate. The documented IV intake is correct. d. The formula strength should be questioned. The formula strength is ordered by the physician. Module: READING MEDICATION LABELS Working With Reading Medication Labels (pp ) 1. a. Coreg 126 Copyright 2012, F. A. Davis Company

165 b. carvedilol c. 25 mg / tablet d. tablet e. oral 2. a. lorazepam b. 4 mg / ml c. liquid for injection (milliliters) d. IV or IM e. Yes f. single-dose g. 0.7 ml 3. a. Diflucan b. fluconazole c. Add 24 ml of distilled water or purified water. Shake well. 4. a. morphine sulfate b. 15 mg / ml c. 20 ml d. SC, IM, IV, epidural or intrathecal e. Yes f. No g. 0.8 ml 5. a. 7.5 ml 6. a. haloperidol b. 50 mg / 10 ml 5 mg / ml c. IM d. No e. No f. 0.5 ml 7. a. Corvert b. 1 mg / 10 ml 0.1 mg / ml c. IV use only d. store at controlled room temperature 127 Copyright 2012, F. A. Davis Company

166 8. a mg / ml b. IV c. No d. 0.5 ml 9. a. 150 mg / 3 ml 10. a. Humulin R b. 500 units 11. a. Novolog b. 6 units 12. a. Novolin 70/30 b. 22 units 13. a. Humalog 50/50 b. 17 units 14. Trade name X Generic name X Dosage strength X Form of the drug Route of administration X Controlled substance X Storage information X Total amount 15. Trade name X Generic name X Dosage strength X Form of the drug X Route of administration Controlled substance Storage information X Total amount 128 Copyright 2012, F. A. Davis Company

167 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Reading Medication Labels (p. 40) d. not administer this drug. CORRECT: The order is for morphine, not hydromorphone. Although both drugs are opioid analgesics, they are different drugs. The nurse needs to ensure that the available drug corresponds to what is ordered. INCORRECT: a. give 1.5 ml of the drug using two vials. Before calculating how much medication to give, the nurse should ensure that correct drug is being prepared. The order is for morphine, not hydromorphone. b. call the pharmacist to double check the order. The nurse should first check the original order found in the Physician s Order sheet. c. research the appropriate route of administration. Although this is important, the nurse should first ensure that the available drug corresponds to what is ordered. Module: ORAL MEDICATIONS Working With Oral Medications (pp ) 1. 2 tablets days 2. 1/2 tablet 14. 1/2 tablet 3. 2 tablets tablet 4. 2 tablets ml 5. 2 tablets ml mg tab (6.25mg) 7. 8 ml mg 8. 2 tsp tablespoon ml tablets tablet ml ml tsp tablets 129 Copyright 2012, F. A. Davis Company

168 24. Digoxin 0.5 tablet Captopril 1 tablet furosemide 2 tabs capsules ml caplets tablets 29. a. 59 ml b. 2 tsp 30. a. 26 ml b. 2 tsp Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Oral Medications (p. 50) b. Call the pharmacist regarding the propranolol. CORRECT: The nurse should call the pharmacist to clarify the propranolol 60 mg ER found in the patient s medication drawer. d. Give the hydralazine and the K-Dur at CORRECT: The nurse can administer the 0900 hydralazine and the K-Dur to the patient. The nurse should not administer the propranolol until it is clarified. INCORRECT: a. Give all the 0900 medications. The nurse should question the propranolol 60 mg ER prior to administering the drug. c. Call the pharmacist regarding the K-Dur. The K-Dur may be given as ordered. e. Give the hydralazine and propranolol at The nurse should hold and question the administration of the propranolol 60 mg ER. 130 Copyright 2012, F. A. Davis Company

169 Module: SYRINGES AND NEEDLES Working With Syringes (pp ) ml ml ml minims minims ml ml 1/2 1/ /2 1/ / / m ml m ml m ml m ml 1 1/ /2 2 1/2 131 Copyright 2012, F. A. Davis Company

170 ml m ml ml ml units UNITS 1/ / /2 USE U-100 INSULIN units USE U-100 INSULIN UNITS units USE U-100 INSULIN UNITS units USE U-100 INSULIN UNITS ml 132 Copyright 2012, F. A. Davis Company

171 units USE U-100 INSULIN units USE U-100 INSULIN UNITS units USE U-100 INSULIN ml ml 1/ / / ml UNITS UNITS ml m ml 133 Copyright 2012, F. A. Davis Company

172 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Syringes (p. 55) d. should divide the medication into two injections, using two 3 ml syringes. CORRECT: For intramuscular (IM) injections, it is recommended that no more than 3 ml be administered into one site. Although the patient would receive two injections, this is the safest action. INCORRECT: a. has correctly determined the most appropriate syringe to measure and administer this dose accurately. For IM injections, it is recommended that no more than 3 ml be administered into one site. b. needs to contact the physician and request a higher dosage strength of the medication. It is not necessary to contact the physician since the ordered dose can be administered through two separate IM injections. c. needs to contact the pharmacist to ensure that the ordered dose has been correctly calculated. The nurse can ask another professional nurse to check the calculation. Working With Needles (p. 56) 1. 28G 1/2 or 31G 5/ G 1 1/ G 3/ G G 5/ G Copyright 2012, F. A. Davis Company

173 Working With Needles (pp ) 1. Meperidine 75 mg (1 ml) IM b. 22G 1 1/2 1/ / /2 2. Filgrastim 300 mcg (1 ml) subcut b. 25G 5/8 1/ / /2 3. Heparin 5000 units (0.67 ml) subcut a m 25G 5/ ml 4. Hepatitis A vaccine 1 ml IM b. 23G 1 1/2 1/ / /2 5. Ketorolac 60 mg (2 ml) IM b. 22G 1 1/2 1/ / /2 135 Copyright 2012, F. A. Davis Company

174 6. Humulin Regular insulin 17 units subcut a. 28G 1/ USE U-100 INSULIN UNITS 7. Humulin Regular insulin 6 units and Humulin NPH insulin 13 units subcut a. 28G 1/2 5 USE U-100 INSULIN UNITS 8. Heparin 1000 units (0.1 ml) subcut a m 25G 5/ ml 9. Morphine sulfate 1 mg (16 minims) subcut b m 25G 1/ ml 136 Copyright 2012, F. A. Davis Company

175 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Needles (p. 60) d. 25G 1/2 CORRECT: Medications ordered via the subcut route are meant to be injected into the adipose tissue. A 25G 1/2 needle will appropriately administer the ordered medication into the correct site. INCORRECT: a. 18G 1 b. c. 20G 1 1/2 22G 1 These needles cannot be used for subcut injections into the abdomen. Module: PARENTERAL MEDICATIONS Working With Parenteral Medications (pp ) ml ml ml 4. 2 ml Fill in the syringe. 1/ / /2 137 Copyright 2012, F. A. Davis Company

176 5. morphine sulfate = 0.6 ml glycopyrrolate = 0.4 ml Total amount = 1 ml Fill in the syringe with the total amount ml Fill in the syringe m ml ml minims m ml ml Fill in the ordered dose in each syringe m ml 1/ / /2 1/ / /2 1/ / /2 138 Copyright 2012, F. A. Davis Company

177 ml Fill in the syringe m ml ml units Fill in the syringe. USE U-100 INSULIN units Fill in the syringe units Fill in the syringe. USE U-100 INSULIN UNITS units Fill in the syringe. USE U-100 INSULIN units Fill in the syringe UNITS UNITS UNITS USE U-100 INSULIN UNITS USE U-100 INSULIN 139 Copyright 2012, F. A. Davis Company

178 units Fill in the syringe. USE U-100 INSULIN UNITS ml ml ml ml ml ml ml ml minims ml m ml ml ml ml 140 Copyright 2012, F. A. Davis Company

179 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Parenteral Medications (p. 71) d ml CORRECT: The dosage strength of levothyroxine is 40 mcg / ml. The ordered dose is mg, which is equivalent to 65 mcg. INCORRECT: a ml Use the dosage strength of 40 mcg / ml as listed under the Usual Dosage information. b ml Use the dosage strength of 40 mcg / ml as listed under the Usual Dosage information. c. 1.5 ml Use the dosage strength of 40 mcg / ml as listed under the Usual Dosage information. Module: RECONSTITUTION OF POWDERED MEDICATIONS Working With Single-Strength Reconstitution (pp ) 1.a. 2.5 ml b. sterile water for injection c. 330 mg / ml d ml 2.a. 4.6 ml b. bacteriostatic water for injection c. 200,000 units / ml d. 1.5 ml 3. date and time of reconstitution; nurse s initials 141 Copyright 2012, F. A. Davis Company

180 4.a. 2 ml b. sterile water for injection c. 125 mg / ml d. 1.6 ml 5.a. 1 g / 2.6 ml b. 1.3 ml 6.a. 2 ml b. sterile water for injection c. 225 mg / 1 ml d. 2 ml 7.a. 9.8 ml b. 5,000 units per ml c. 1.2 ml d. date and time of reconstitution; nurse s initials ml Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Single- Strength Reconstitution (p. 78) c. Question the date of reconstitution. CORRECT: Although the nurse s initials and time of reconstitution are written, the date of reconstitution is not written on the Augmentin label. The nurse needs to clarify this prior to administering the drug to the patient. INCORRECT: a. Convert the tsp to ml. The nurse may want to do this prior to administration, however, it is more important to first clarify the date of reconstitution. b. Administer the measured dose. The nurse must first clarify the date of reconstitution. d. Use a 3 ml syringe to measure the dose. It is more important to first clarify the date of reconstitution. 142 Copyright 2012, F. A. Davis Company

181 Working With Multiple-Strength Reconstitution (pp ) 1. the smallest volume of diluent 2.a. 100 mg / ml b. 7.5 ml c. date and time of reconstitution; nurse s initials; circle selected volume of diluent and corresponding dosage strength 3.a. 100,000 units / ml b. 500,000 units / ml c. 9.6 ml of diluent give 10 ml 4.6 ml of diluent give 5 ml 1.6 ml of diluent give 2 ml 4.a. 75 ml of diluent 250,000 units / ml 33 ml of diluent 500,000 units / ml 11.5 ml of diluent 1,000,000 units / ml b. 75 ml of diluent give 3 ml 33 ml of diluent give 1.5 ml 11.5 ml of diluent give 0.75 ml c. 7 days d. date and time of reconstitution; nurse s initials; circle selected volume of diluent and corresponding dosage strength 5.a. 3.5 ml of diluent 500 mg / ml 7.2 ml of diluent 250 mg / ml b. 3.5 ml of diluent give 1.4 ml 7.2 ml of diluent give 2.8 ml c. 1 hour at room temperature; 6 hours under refrigeration d. 3.5 ml is preferable so that the volume of the IM injection is smaller. e. date and time of reconstitution; nurse s initials; circle selected volume of diluent and the corresponding dosage strength 143 Copyright 2012, F. A. Davis Company

182 6.a. After reading the label, the nurse can identify the (check all that apply): X routes of administration X storage information b. To administer the ordered dose (500 mg), the nurse: X should read the accompanying literature. Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Multiple-Strength Reconstitution (p. 84) b. Recalculate the dose drawn up. CORRECT: The circle around the dosage strength indicates that the drug has already been reconstituted. The reconstituted drug yields 500,000 units / ml. The order is for 2,400,000 units. After calculating, the nurse will draw up 4.8 ml. INCORRECT: a. Add the 5 ml to the IV bag. The order is for 2,400,000 units. After calculating, the answer is 4.8 ml. The nurse can accurately measure this dose using a 5 ml syringe. c. Add 9.6 ml of penicillin G potassium to the IV bag. The nurse needs to use the reconstituted dosage strength that is circled on the label. d. Use 1,000,000 U / ml to calculate the desired dose. The nurse needs to use the reconstituted dosage strength that is circled on the label. Module: IV CALCULATIONS Working With Milliliters per Hour (pp ) ml / hr ml / hr ml / hr 144 Copyright 2012, F. A. Davis Company

183 ml / hr ml / hr ml / hr ml / hr ml / hr ml / hr ml / hr Working With Flow Rate (p ) gtt / min gtt / min gtt / min 4. 8 gtt / min gtt / min gtt / min gtt / min gtt /min gtt / min gtt / min Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Milliliters per Hour and Flow Rate (p. 89) a. continue to monitor the IV intake at 13 gtt / min. CORRECT: The IV is set at the appropriate rate to deliver 50 ml / hr. INCORRECT: b. question the oral intake for the day shift. There is no indication for questioning the oral intake in this situation. c. increase the flow rate to 31 gtt / min. The IV rate is accurate and should not be increased without an MD order. d. change the IV tubing to a minidrop. The IV tubing does not need to be changed. The flow rate can be accurately set and monitored with the current tubing. 145 Copyright 2012, F. A. Davis Company

184 Working With Direct IV Medication Administration (pp ) 1. 5 minutes minutes 3. 4 minutes 4. 5 minutes 5. 2 minutes 6. 1 minute 7. 2 minutes Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Direct IV Medication Administration (p. 93) b. administer 0.8 ml over 1 minute. CORRECT: The recommended rate for direct IV administration is 1 minute. INCORRECT: a. give the ordered dose slowly into the vein. For safe administration, the nurse needs to follow the recommended rate and routes of administration. c. add the atropine dose to the primary IV fluid. The order is for IVP (direct IV administration). The atropine should not be added to the primary IV fluid. d. dilute with 10 ml normal saline. The drug reference information indicates that this drug should be administered undiluted. Working With Infusion Time (pp ) 1. 8 hours 2. 8 hours 20 minutes hours 20 minutes 4. 6 hours 24 minutes minutes 6. 3 hours 20 minutes 146 Copyright 2012, F. A. Davis Company

185 Working With Completion Time (pp ) 1. 4:00 PM or :10 PM or :00 AM or :30 AM or :45 PM or :00 PM or 1400 Working With Infusion and Completion Time (pp ) 1. Infusion time = 9 hours Completion time = 8:00 PM or Infusion time = 3 hours 30 minutes Completion time = 7:00 PM or Infusion time = 5 hours Completion time = 1:00 AM or Infusion time = 4 hours 40 minutes Completion time = 11:40 AM or Infusion time = 5 hours Completion time = 2:00 AM or 0200 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Infusion and Completion Time (p. 98) a. Increase the flow rate to 31 gtt / min. CORRECT: The nurse should increase the flow rate to administer 125 ml / hr. c. Report a completion time of CORRECT: At 1200, there are 700 ml of fluid left in the primary IV. Following the physician s orders to administer 125 ml / hr, it will take 5 hours and 36 minutes for 700 ml at 1200 to infuse into the patient. INCORRECT: b. Increase the flow rate to 41 gtt / min for 4 hours. The flow rate should not be adjusted to catch up. d. Plan to give 1000 ml for the day shift. The nurse must document the actual amount of IV fluid given for the shift. Because the IV is behind, the patient will not receive 1000 ml for the shift. e. Administer the IV fluid through an infusion pump. The IV has been ordered to infuse via gravity. The nurse should assess the IV site to ensure proper placement. 147 Copyright 2012, F. A. Davis Company

186 Labeling IV Bags (pp ) 1. Start 2. Time Start Time Start Time ml 0 0 5% Dextrose Injection Copyright 2012, F. A. Davis Company

187 4. Start Time ml % Normal 100 Saline Start Time ml % Normal Saline Copyright 2012, F. A. Davis Company

188 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Labeling IV Bags (p. 102) d. must be recalculated. CORRECT: The nurse has made an error in the markings of the hourly fluid intake, beginning with the hourly fluid level at 1400, which should be at the 400 ml fluid level. INCORRECT: a. is labeled appropriately. There is an error with the hourly fluid level marking beginning at b. reflects the increased rate. The hourly fluid level intake is marked incorrectly on the flowmeter beginning at c. indicates when the IV will be finished. Since the hourly fluid level is not correct, the completion time is also incorrect. Module: PEDIATRIC CALCULATIONS Administering Medications to Children (pp ) 1. 2 tablets ml 3. 6 ml 4. 3 ml 5a. 2.5 ml b. 1/ / /2 6a ml b m ml 150 Copyright 2012, F. A. Davis Company

189 ml 8a. 100 gtt / min b ml / hr Dosage Based on Body Weight (pp ) 1a. 210 mg q.12h. b. Yes, the dose is safe. 2a. 400 mcg / dose b. Yes, the dose is safe. 3a. 180 mg / day b. Yes, the dose is safe. 4a mg q.3-4h. b. No, the dose is not safe. 5a mg / dose b. Yes, the dose is safe. Dosage Based on Body Surface Area (pp ) 1a. 5.6 mg q.6h b. Yes, the dose is safe. 2a. 198 mg / dose b. No, the dose is not safe. 3a mg /q.1-2 weeks up to 12 weeks b. No, the dose is not safe. 4a mg / day b. Yes, the dose is safe. 5a. 590 mg q.8h. for 7 days b. Yes, the dose is safe. 151 Copyright 2012, F. A. Davis Company

190 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Determining Safe Dose (p. 111) b. Question the ordered dose. CORRECT: The recommended total daily initial dose for a child weighing 27 kg is 16.2 mg / day. The order is for 10 mg b.i.d. The child will receive 20 mg /day. INCORRECT: a. Administer the medication as ordered. The nurse should first question the ordered dose, since it is more than the recommended initial dose. c. Ask the pharmacist if the ordered dose is correct. The nurse should communicate directly with the physician and clarify the ordered dose. d. Ask the parent what dose the child has been taking. The situation indicates that the physician is starting lamotrigine drug therapy on the child. Working With Nasogastric Fluid Replacement Problems (pp ) 1a. 100 ml / hr b. 150 ml / hr c. 7 hours 36 minutes d or 10:36 PM 2a. 63 ml / hr b. 22 ml / hr c. 3 hours d or 3:00 PM 3a. 4 hours b or 8:30 AM 4a. 4 hours 30 minutes b or 3:15 AM 5a. 2 hours 36 minutes b or 6:36 PM 6a. 3 hours 17 minutes b or 10:17 AM 152 Copyright 2012, F. A. Davis Company

191 Module: TITRATION OF IV MEDICATIONS Titration in Common Clinical Practice (pp ) ml / hr ml / hr mg / hr ml / hr 5. 6 ml / hr 6a. 55 ml / hr b. 66 ml / hr Complex Titration Problems in Critical Care (pp ) 1. a. 6 mg / hr b. 6 ml / hr 8. 3 ml / hr c. No ml / hr 2. a. 60 mg / hr ml / hr b. 15 ml / hr ml / hr c. 30 ml / hr ml / hr 3. a. 120 ml / hr ml / hr b. 60 ml / hr 14. a. Yes ml / hr b. 51 ml / hr mg / hr 6. 4 mg / min ml / hr 153 Copyright 2012, F. A. Davis Company

192 Exercise: FOCUS ON SAFETY Making Clinical Judgments in Working With Titration Medication (p. 120) a. set the infusion rate at 28 ml / hr. CORRECT: After calculating, the nurse will infuse the heparin at 28 ml / hr. d. set up the IV using an infusion pump. CORRECT: The nurse will infuse the heparin at 28 ml / hr using an infusion pump. INCORRECT: b. set the infusion rate at gtt / min. Heparin is a high alert drug. It is safer to administer this drug through an infusion pump (ml / hr). c. use a minidrop IV tubing for gravity flow infusion. Heparin is a high alert drug. Therefore, every effort must be made to ensure accuracy in the administration of the ordered dose. An infusion pump accurately delivers the set rate. e. discontinue the IV once the 500 ml have infused. This is a continuous infusion and should not be discontinued without the physician s order. 154 Copyright 2012, F. A. Davis Company